Long-term outcomes in Children with Aortiv Mechanical Valves

[Guest]

J Heart Valve Dis. 2005 Mar;14(2):166-71.

Mechanical aortic valve replacement: long-term outcomes in children.

Shanmugam G, MacArthur K, Pollock J.

Department of Cardiac Surgery, Royal Hospital for Sick Children, Glasgow, UK.

BACKGROUND AND AIM OF THE STUDY: Early and late outcomes following mechanical aortic valve replacement (AVR) in children were analyzed. METHODS: Between January 1980 and December 2003, 55 patients underwent mechanical AVR at the authors' institution. Of these patients, 12 had aortic regurgitation (AR), 31 had aortic stenosis (AS), and 12 had mixed disease. Preoperatively, 25 patients (45.5%) were in NYHA classes III and IV. Among patients, 22 had a previous valvotomy and 19 had associated cardiac defects. Isolated AVR was performed in 37 cases. Twelve patients required root enlargement procedures, two had aortic root replacement, three had a double valve replacement, and one patient had a concurrent mitral annuloplasty. The mean prosthesis size was 22.6 mm (range: 16-31 mm). Mean follow up was 12.28 +/- 6 years (range: 1-23 years); total follow up was 665 patient-years (pt-yr). RESULTS: There was one late death. Actuarial survival at 20 years was 98 +/- 2%. Event-free survival at one, five and 20 years was 96 +/- 3%, 92 +/- 4% and 88 +/- 5%, respectively. Four patients required reoperation (two for valve outgrowth, one each for paravalvular leak and prosthetic valve endocarditis (PVE)). Freedom from reintervention at one, five and 20 years was 98 +/- 2%, 96 +/- 3% and 92 +/- 4%, respectively. There was one event of anticoagulation-related hemorrhage. Freedom from anticoagulant-related hemorrhage at 20 years was 98 +/- 2%, and freedom from PVE at five and 20 years was 98 +/- 2% and 96 +/- 3%, respectively. There were no instances of thromboembolism or structural valve dysfunction. Linearized rates of bleeding and endocarditis were 0.15 and 0.3% per pt-yr, respectively. At follow up, 54 children were in NYHA classes I or II. CONCLUSION: Mechanical AVR, with aortic root enlargement if necessary, is associated with low mortality and morbidity, and is an excellent treatment option in children. Late embolic and hemorrhagic complications are infrequent in the current era.

 

[Emma]

wow!

wow!

that sounds good Al! (from what I can make out amongst all the medical 'jargon'!)
have they done anything with a mitral valve like that??

Emma
xxx

 

[Guest]

Haven't seen anything, but I am always looking.

 

[RCB]

Amazing!

Amazing!

Over 1,000 pt. years and.........
"There were no instances of thromboembolism or structural valve dysfunction." Doesn't that go against traditional statistics? A bleeding event, but no deaths- truly amazing!

 

[Guest]

Children are much more resilient than adults. If I took care of only kids, I'd have fabulous statistics.

 

[tobagotwo]

It is good. Kids need a chance.

To clarify (if I understand it), there were 665 patient-years of use in the study. The average length of time with the valve in the study was about twelve and a half years. The study ranged from one who had had his valve for 23 years, to one who had had it for only one year.

Almost half had been in NYHA class III or IV when they received the valve, and all but one had improved to class I or II. Even though they received the valve as children, only two outgrew the valve, thanks to root enlargement procedures, and only two others had to have the valve replaced for other reasons, meaning only about 7% replaced overall (none for valve failure).

Especially considering this was such a mixed bag of problem hearts to begin with, this is an excellent result. Children present a special challenge for surgeons, and because most of them were likely congenital issues, any of them could have been a surprise package when they were opened up. Three cheers for the surgeons!

Best wishes,

 

[RCB]

Still with 665 years...

Still with 665 years...

it is still an amazing figure. One would wonder with the way kids eat
today, how could they keep there INRs so consistant. It certainly is evidences of better control of INR to lower the dangers of being on warfarin.
Maybe with more studies of this type, they will have to rethink the risk percentages of being on warfarin.

They didn't say what type of valves were being used, but I would assume they wouldn't be first or second generation valve that were the basis for the
percentages used today. I guess one would think better valves- lower risk with ACT.

 

[Guest]

Add to this the facts that they started the series in 1980 when warfarin was not as well understood as it is today. Also, some of the valves represented 1970s technology - think how much better the valves are today and how much better this study would look if it were starting in 2000 and going out to 2015. The kids getting valves today are getting much more advanced technology. This study sort of represents a worst case scenario because the starting date is so far back.

When RCB got his valve back in 1960, he had a life expectancy of about 1 month. If the life expectancy was longer than that the doctors could not operate on that person because nobody had lived longer than that. Valve replacement was a heroic, last-ditch effort in that era. If parents wonder how kids will do, they should look at him. Still ticking almost 45 years later. In my opinion, if you want to look for a true hero, everyone on this website probably has benefitted from what doctors learned from treating him.

He will probably say that he is not a hero, that he just did what needed to be done. Pueblo has produced four Medal of Honor winners and that is what they all said, "I just did what needed to be done." Robert "Jerry" Murphy is one of those heroes from the Korean War. Guess what he does today. He volunteers to push veterans around in wheelchairs at the VA Hospital in Albuquerque. That is why I look at RCB as a hero.

 

[RCB]

Thank Al, but

Thank Al, but

I did not volunteer for my surgery nor affect an outcome. Medal Of Honor
winners are very special people who really had to be both brave and choose to do what they did. I know you did not mean to make the comparison and
I need to state that I am in no way in the class of these Medal of Honor winners. Pueblo is indeed fortunate to have four of them.
Few people know this, but when one is wearing the ribbon, no matter what the rank is, a person in uniform is supposed to salute the medal. In words, a five star general would salute the medal if worn by a private. Of course like Retreat, where few people stop(even in uniform) I suppose this great tradition may not be honored in more.

 

[Guest]

I did mean to make the comparison. Like you, most of them did not volunteer - the situation was there and there was no way out but the course that they took.

You did influence outcomes. You were certainly discussed at medical meetings. Your doctors telling others of how well you did gave other doctors permission to try the surgery on others. If it were not for a few people like you way back before most of the members on this site were born, they would have never had a chance.

Everyone on here should salute the metal in your chest.

BTW for those of you who don't have military experience - retreat is the end of the day when the flag is taken down - not the giving up of a position.