Artificial Organs

33(11):915–921, Wiley Periodicals, Inc.

© 2009, Copyright the Authors
Journal compilation © 2009, International Center for Artificial Organs and Transplantation and Wiley Periodicals, Inc.

Mechanical Aortic Valve Replacement in Children

and Adolescents After Previous Repair of Congenital
Heart Disease

*Aron-Frederik Popov, *Kasim Oguz Coskun, *Theodor Tirilomis, *Jan Dieter Schmitto,
†José Hinz, ‡Thomas Kriebel, *Friedrich Albert Schoendube, and *Wolfgang Ruschewski
*Department of Thoracic Cardiovascular Surgery; †Department of Anaesthesiology, Emergency and Intensive
Care Medicine; and ‡Department of Pediatric Cardiology and Intensive Care Medicine, University of Göttingen,
Göttingen, Germany

Abstract: Due to improved outcome after surgery for
congenital heart defects, children, adolescents, and grown-
ups with congenital heart defects become an increasing
population. In order to evaluate operative risk and early
outcome after mechanical aortic valve replacement
(AVR) in this population, we reviewed patients who
underwent previous repair of congenital heart defects.
Between July 2002 and November 2008, 15 (10 male and
5 female) consecutive patients (mean age 14.5 ⫾ 10.5
years) underwent mechanical AVR. Hemodynamic indica-
tions for AVR were aortic stenosis in four (27%), aortic
insufficiency in eight (53%), and mixed disease in three
(20%) after previous repair of congenital heart defects.
All patients had undergone one or more previous cardio-
vascular operations due to any congenital heart disease.
Concomitant cardiac procedures were performed in all of
them. In addition to AVR, in two patients, a mitral valve
exchange was performed. One patient received a right
ventricle-pulmonary artery conduit replacement as con-
comitant procedure. The mean size of implanted valves
was 23 mm (range 17–29 mm). There were neither early
deaths nor late mortality until December 2008. Reopera-
tions were necessary in five (33%) and included implan-
tation of a permanent pacemaker due to complete
atrioventricular block in two (15%), mitral valve replace-
ment with a mechanical prosthesis due to moderate to
severe mitral regurgitation in one (7%), aortocoronary
bypass grafting due to stenosis of a coronary artery in one
(7%), and in one (7%), a redo subaortic stenosis resection
was performed because of a secondary subaortic stenosis.
At the latest clinical evaluation, all patients were in good
clinical condition without a pathological increased
gradient across the aortic valve prosthesis or paravalvular
leakage in echocardiography. Mechanical AVR has excel-
lent results in patients after previous repair of congenital
heart defects in childhood, even in combination with
complex concomitant procedures. Previous operations
do not significantly affect postoperative outcome.
Key Words: Reoperation—Mechanical aortic valve
replacement—Congenital heart disease.

Despite steady improvements in the results of
cardiac surgery, there has been a trend in operating
on higher-risk patients, which leads to increased mor-
bidity and mortality. Children and adolescents, after
previous repair of congenital heart disease, are an
doi:10.1111/j.1525-1594.2009.00886.x
Received May 2009; revised June 2009.
Address correspondence and reprint requests to Dr. Aron-
Frederik Popov, Department of Thoracic and Cardiovascular
Surgery, University of Göttingen, Robert-Koch-Strasse 40, 37099
Göttingen, Germany. E-mail: popov@med.uni-goettingen.de
Presented in part at the 5th International Conference Pediatric
Mechanical Circulatory Support Systems & Pediatric Cardiopul-
monary Perfusion held May 27–30, 2009 in Dallas, TX, USA.
increasing challenge for pediatric cardiologists and
cardiac surgeons, as improved diagnostic and thera-
peutic tools allow the majority of newborns with con-
genital heart disease to survive to adulthood.
The grown-ups with congenital heart defects
(GUCH) are a very inhomogeneous group of
patients with a broad spectrum of different diagnoses
with variable morphology and pathophysiology.
Many GUCH, however, require reoperations for
definitive corrective repair, residual and or new
lesions, additional palliative procedures, and some of
them need replacement of valves.
Aortic valve replacement (AVR) represents one of
several treatment options currently available for

915

aor_886 915..921

916 A.-F. POPOV ET AL.
children, adolescents, and GUCH presenting with
severe aortic valve (AV) lesions not suitable for
valve-sparing surgical procedures. However, AVR is
associated with specific disadvantages. Bioprostheses
are considered unsuitable for children due to their
early degeneration (1), whereas homografts for AVR
that provide excellent hemodynamics are resistant
to infection and allow implantation even in small
patients. However, their early degeneration is com-
parable to that of bioprostheses and thus constitutes
a major drawback (2). Pulmonary autografts, used in
the Ross procedure, do not degenerate and have a
growth potential (3), but this procedure creates a
new pathology on the right ventricular outflow tract
(RVOT), and the fate of the pulmonary valve is
still uncertain. The use of a mechanical prosthesis,
however, is often criticized because of possible com-
plications, inconvenience from anticoagulation (4),
and need for reoperation because of outgrowth.
The purpose of the present study was to review the
experience with mechanical AVR in patients with
previous repair of congenital heart defects retrospec-
tively and to evaluate early and midterm survival
rates, morbidity, and complication.
PATIENTS AND METHODS
Study population
Between July 2002 and November 2008, 15 con-
secutive patients (median age 14.5 ⫾ 10.5 years,
range 4.1 month–40.3 years) underwent AVR with a
mechanical prosthesis at our institution. Five were
female patients and 10 were male. All patients had
undergone one or more previous cardiovascular
operations due to congenital heart disease.
Before AVR, two (13%) had undergone percuta-
neous AV interventions, 15 (100%) had undergone at
least one previous surgical intervention, 10 (67%)
had undergone two previous surgical interventions,
and two (13%) had undergone three previous surgi-
cal interventions to address AV lesions, other cardiac
lesions, or both. The mean age at first operation was
2.5 ⫾ 4.8 years (range, 0.1–17), 5.4 ⫾ 3.1 years (range,
0.4–12) at the second operation, and 7 ⫾ 0 years
(range, 0.4–7) at the third operation.
All patients in the study had two-dimensional
echocardiograms with Doppler studies and cardiac
catheterization before AVR. Echocardiography
evaluation was reported as the mean value ⫾
standard deviation. Hemodynamic indications for
AVR were aortic stenosis in four (27%), aortic insuf-
ficiency in eight (53%), and mixed disease in three
(20%) after previous repair of congenital heart
defects. Left ventricular (LV) systolic function was
Artif Organs, Vol. 33, No. 11, 2009
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assessed by the determination of the shortening frac-
tion and was within normal ranges in most patients
(shortening fraction, 37% ⫾ 6.1; range, 25% to 47%).
Measurements of left ventricular end-diastolic
diameter were available in all patients (median,
48 ⫾ 8.4 mm; range, 31 to 61 mm).The LV end-systolic
diameter was found to be normal in all patients
(median, 30 ⫾ 4.5 mm; range, 23 to 40 mm).
Genetic malformations affecting the heart, aorta,
and other major vessels were seen in seven patients.
One patient (7%) had Shone’s complex, one (7%)
had Turner syndrome, one (7%) had Smith–Lemli–
Opitz syndrome, one (7%) Rubinstein–Taybi syn-
drome, one (7%) had DiGeorge syndrome, one (7%)
had Williams–Beuren syndrome, and one (7%) had
Noonan syndrome documented by chromosomal
analysis. Preoperative characteristics of the patients
at the time of AVR are shown in Table 1.
Previous cardiac surgical procedures
All patients had undergone previous cardiac surgi-
cal procedures due to congenital heart disease with a
variety of abnormalities. They had undergone a total
of 31 cardiac surgical operations (at our institution or
another) with an average of 2.1 ⫾ 1.3 surgical inter-
ventions per patient before AVR. Details are summa-
rized in Table 2.
Surgical procedure
Midline resternotomy was performed and standard
cardiopulmonary bypass (CPB) with systemic (18–
28°C) hypothermia, established via ascending
aortic and single atrial or bicaval cannulation, and
for myocardial protection crystalloid cardioplegia
(Brettschneider’s solution) were used in all cases. The
individual AV annulus was measured at surgery using
calibrated Hegar dilators. All mechanical prostheses
were positioned in the subcoronary position using an
Ethibond-interrupted suture technique. In all cases, a
mechanical St. Jude Medical valve was implanted.
Transesophageal echocardiographic control was
performed before protamine administration and
removal of cannulas to confirm adequate valve func-
tion and complete air evacuation.
Definitions
Operative mortality includes death occurring
within 30 days after the operation or during the same
hospital admission. Deaths taking place more than 30
days postoperatively following the patient discharge
from hospital are termed late deaths. Freedom
from cardiovascular events contains thromboembo-
lism, anticoagulation treatment bleeding, any valve-
related event, and any reoperation.
 15251594, 2009, 11, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/j.1525-1594.2009.00886.x by Egyptian National Sti. Network (Enstinet), Wiley Online Library on [07/04/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
MECHANICAL AORTIC VALVE REPLACEMENT IN CHILDREN, ADOLESCENTS, AND GUCH 917

TABLE 1. Clinical characteristics

No. or Percentage
Patient characteristics mean ⫾ SD (%) or range
No. of patients 15
Age (years) 14.9 ⫾ 10.5 0.3–40
Sex
Male 10 67
Female 5 33
Previous cardiac operation
One previous operation 15 100
Two previous operations 10 67
Three previous operations 2 13
Age at previous operation
1st operation 2.5 ⫾ 4.8 0.1–17
2nd operation 5.4 ⫾ 3.1 0.4–12
3rd operation 7⫾0 0.4–7
Aortic valve lesion
Stenosis 4 27
Insufficiency 8 53
Mixed 3 20
Echocardiography data preoperative
LVEDD (mm) 48 ⫾ 8.4 31–61
LVESD (mm) 30 ⫾ 4.5 23–40
FS (%) 37 ⫾ 6.1 25–47
Genetic cardiovascular anomalies (syndromes) 7 47

LVEDD, left ventricular end-diastolic dimension; LVESD, left ventricular end-systolic

dimension; FS, fractional shortening.

Anticoagulation graphy was performed by a pediatric cardiologist

All patients were given phenprocoumon orally,
aiming to maintain a closely monitored international
normalized ratio (INR) within the range of 2.5 to 3.0
for AVR and 2.5 to 3.5 for mitral valve replacement
(MVR).
Follow-up
No patients were lost to follow-up. Follow-up time
ranged from 2 to 66 months (mean 30 months, cumu-
lative 488 patient months). Transthoracic echocardio-
postoperatively before discharge from our hospital.
The patients were then examined by the referring
cardiologist at regular intervals or in our institution
by a pediatric cardiologist. The echocardiographic
data for the study were taken from the cardiologists’
report.
Statistical analysis
Statistical analysis was performed by using com-
mercial statistic software (Statistica 5.1, StatSoft, Inc.,

TABLE 2. Previous cardiac surgical procedures

Number of Percentage
Previous operations patients, mean ⫾ SD (%)
Aortic valve commissurotomy 5 16
Resection of subaortic stenosis 4 13
Repair of supravalvular stenosis 4 13
Repair of coarctation aorta 2 6.5
Repair of aortic valve 1 3
Ventricular septal defect closure 2 6.5
Intraventricular tunnel repair 1 3
Complete atrioventricular septal defect repair 2 6.5
Mitral valve replacement 1 3
Pulmonary valve replacement (Homograft) 1 3
Pulmonary valve replacement 2 6.5
Correction of TGA 2 6.5
Correction of Fallot 2 6.5
Balloon aortic valvuloplasty 2 6.5
Total 31 100
Average per patient 2.1 ⫾ 1.3

TGA, transposition of great arteries.

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918 A.-F. POPOV ET AL.

Tulsa, OK, USA). Freedom from time-related events
was calculated using the product-limit method of
Kaplan–Meier.
RESULTS
Operative results
All patients survived the operation. The mean size
of implanted valves was 23 mm (range, 17–29 mm). In
all cases, 27 concomitant procedures were performed
with an average of 2 ⫾ 1.3 (range, 1–3) per patient.
These were implantation of a composite mechanical
prosthesis in one, resection of subaortic stenosis
(SAS resection) in five, an ascending aortic enlarge-
ment in four, an aortic replacement in one, closure of
a ventricular septal defect in two, closure of an atrial
septal defect in one, a conduit replacement in two,
RVOT procedures in one, mitral valve procedures
(including MVR) in two, pulmonary valve proce-
dures (including pulmonary valve replacement) in
two, a tricuspid valve procedure in one, coronary pro-
cedures in two, and miscellaneous procedures in
three. The median CPB time at surgery was 259 min
(range, 100–411 min), and the median aortic cross
clamp time was 142 min (range, 60–227 min). The
mean body core temperature was 23 ⫾ 4°C (range,
18–28°C). The median intensive care unit stay was
15 ⫾ 34 days (range, 1–133 days) and the median hos-
pital stay was 30 ⫾ 35 days (range, 11–150 days). All
details are summarized in Table 3.
Complications and reoperations
At follow-up, midterm data (30 ⫾ 23 months) could
be obtained for all patients (100%). Quality of life was
considered normal in 14 (93%), and severely dimin-
ished in one (7%). A thromboembolic event was
observed in one patient. This patient suffered from a
stroke and lives in a care facility for children.
Reoperation was necessary in five (33%) and
included implantation of a permanent pacemaker due
to complete atrioventricular block in two (15%),
MVR with a mechanical prosthesis due to moderate
to severe mitral regurgitation in one (7%), aortocoro-
nary bypass grafting due to stenosis of a coronary
artery in one (7%), and in one (7%), a redo subaortic
stenosis resection was performed because of a second-
ary subaortic stenosis. No complications occurred
because of multiple redo sternotomies due to previous
cardiac surgical procedures. No patients had mechani-
cal valve endocarditis. There were no hemorrhagic
events such as gastrointestinal or cerebral bleeding
observed during follow-up. Kaplan–Meier freedoms
from any cardiovascular events (including cardiologi-
cal or surgical reintervention) at 60 months were 52%
(Fig. 1).
Echocardiography
Postoperative echocardiography at follow-up was
performed in all patients. Echocardiographic data are
summarized in Table 4. Fractional shortening of the
left ventricle was normal in all patients (35% ⫾ 10.6;

TABLE 3. Operations data and surgical procedures at the time of mechanical

aortic valve replacement
Range or % of
n = 15 Mean ⫾ SD procedures
Cardiopulmonary bypass time (min) 245 ⫾ 29 100–411
Aortic cross clamp time (min) 142 ⫾ 24 60–227
Body core temperature (°C) 23 ⫾ 4 18–28
Prosthesis size (mm) 23 17–29
Concomitant procedures
Composite mechanical prosthesis 1 3.7
SAS resection 5 18.5
Ascending aortic enlargement 4 14.8
Aortic replacement 1 3.7
Closure of residual VSD 2 7.4
Closure of ASD 1 3.7
Conduit replacement 2 7.4
RVOT procedures 1 3.7
Mitral valve procedures 2 7.4
Pulmonary valve procedures 2 7.4
Tricuspid valve procedures 1 3.7
Coronary procedures 2 7.4
Miscellaneous 3 11.1
All operations (concomitant procedures) 27 100
Average per patient 2 ⫾ 1.3 1–3
ICU stay (days) 15 ⫾ 34 1–133
Hospital stay (days) 30 ⫾ 35 11–150

SAS, subaortic stenosis; VSD, ventricular septal defect; ASD, atrial septal defect; RVOT,
right ventricular outflow tract; ICU, intensive care unit.

Artif Organs, Vol. 33, No. 11, 2009

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MECHANICAL AORTIC VALVE REPLACEMENT IN CHILDREN, ADOLESCENTS, AND GUCH 919

DISCUSSION
(% ) Freedom from cardiovascular events

100
80
60
40
20
0 eases, and some have survived with secondary cardiac
0 10
Number at risk
15 12
FIG 1. Kaplan–Meier freedoms from any cardiovascular events
(including cardiological or surgical reintervention) at 60 months
were 52%.
range, 24% to 45%). Measurements of left ventricu-
lar end-diastolic diameter were in normal ranges
(51 ⫾ 5.1 mm, median; range, 42–61 mm). The LV
end-systolic diameter was found to be normal in all
patients (median, 34 ⫾ 5.4 mm; range, 27–42 mm).
Four patients had mild AV regurgitation and two
patients showed a mild mitral regurgitation without
hemodynamic significance. Transvalvular gradients
were within a clinically acceptable range and no para-
valvular leakage in echocardiography was found.
Midterm survival and functional status
There was no late death.Two patients showed a mild
mitral regurgitation without hemodynamic signifi-
cance. At the latest clinical examination, all patients
were in New York Heart Association (NYHA) func-
tional class I leading normal or near-normal lives.
As a result of increasing survival rates for children
with congenital heart disease over the last decades, a
new patient population of adults with congenital
heart disease is emerging today.
Patients with both native unoperated and operated
malformations contribute to the GUCH population.
Survivors without surgical treatment mainly have
simple malformations, but a few have complex dis-
20 30 40 50 60 lesions. Among operated malformations, there are
Follow up (months) patients with a “complete” repair (anatomical and
physiological), others with a definitive palliation
8 6 6 4 1
(physiological repair), and some with a simple
palliation. The clinical spectrum is obviously diversi-
fied, depending on the underlying anomaly, surgical
outcome, presence of residua, sequelae and/or com-
plications, length of follow-up, and comorbidities.
However, reports of experiences with reoperations
for congenital heart disease are rare.
In some cases, children, adolescents, and GUCH
require reoperations for definitive corrective repair,
residual and/or new lesions, and additional palliative
procedures. Others need replacement of valves if
reconstruction is impossible or fails. The selection of
the most appropriate substitute in those with irrepa-
rable AV lesions remains controversial.
Potential complications after implantation of
mechanical valve prosthesis are thrombosis, hemor-
rhage, cerebral embolism, endocarditis, ventricular
arrhythmias, and ventricular failure. Repeated valve
replacement will be needed in some cases during
childhood because of somatic growth (5). However,
although the Ross procedure has growth potential
and does not require long-term anticoagulation,

TABLE 4. Latest follow-up

Number of patients
(%) or mean ⫾ SD Range
Survival 15 (100)
Reoperation 5 (33)
Mitral valve replacement 1 (7)
Coronary artery bypass grafting 1 (7)
Redo SAS resection 1 (7)
Pacemaker implantation 2 (15)
Thomboembolic events 1 (7)
Hemorrhagic events 0
Echocardiography data postoperative
LVEDD (mm) 51 ⫾ 5.1 42–61
LVESD (mm) 34 ⫾ 5.4 27–42
FS (%) 35 ⫾ 10.6 24–45

SAS, subaortic stenosis; LVEDD, left ventricular end-diastolic dimension; LVESD, left ven-
tricular end-systolic dimension; FS, fractional shortening.

Artif Organs, Vol. 33, No. 11, 2009


920 A.-F. POPOV ET AL.
the procedure is technically demanding, and late
autograft failure, aortic root dilatation, and homo-
graft reoperations are common (6–8).
Moreover, AV repair is an attractive alternative to
valve replacement due to durability of the native AV,
good hemodynamics, and avoiding anticoagulation
therapy (9). However, more studies comparing repair
and replacement of the AV are needed in order to
elucidate which groups of patients are suitable for
each type of procedure.
Our study reports a single institution’s experience
with AVR using mechanical valves in 15 children who
underwent previous repair of congenital heart
defects. The absence of early or late mortality in this
study is most gratifying and reflects improvements
made in cardiac surgical technique, preoperative
clinical diagnostics, and postoperative intensive care.
It compares well with the lowest reported mortality
rates for mechanical valve replacement in pediatric
patients of 0 to 10% for AVR (10–12), although our
series contains even GUCH. However, it is difficult to
compare our results with the rare comparative data
available from the literature because most published
series present mixed populations with first and re-
operations or with different cardiac anomalies. For
example, Berdat et al. (13) had 7.6% early mortality
in their study of reoperations in GUCH; Monroe
et al. (14) had an overall operative mortality of 6.9%
in only children over a 25-year period; Klcovansky
et al. (15) had an overall mortality of 1.3% in GUCH
over an 8-year period; and Luciani et al. (16) had an
excellent survival rate of 99% in adults with congeni-
tal heart disease over a 5-year period.
Recently, a large European multicenter study (17)
showed a hospital mortality of 4.1 % for GUCH in a
subgroup analysis of 2012 adult patients.
Actuarial freedom from any cardiovascular events
(including cardiological or surgical reintervention) at
60 months was 52%. However, we did not classify the
cardiovascular events in different groups because our
sample size was too small. Therefore, “any cardiovas-
cular event” comprises thromboembolism, anticoagu-
lation treatment bleeding, any valve-related event,
and any reoperation. Luciani et al. (16) demonstrated
that AV surgery in adults with congenital heart
disease can be performed safely with low mortality
and with 98% freedom from reoperation at 5 years.
In our series, reoperation (including implantation of
a permanent pacemaker due to complete atrioven-
tricular block) after AVR was necessary in five (33%)
and was also acceptable.
Our data are almost identical to those reported by
Alexiou and associates (5) and Arnold and cowork-
ers (12) concerning the cardiovascular events. In
Artif Organs, Vol. 33, No. 11, 2009
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one case, we found subaortic stenosis in a patient
who required a second operation after mechanical
AVR. It has been reported after surgical repair of
several congenital heart defects that a recurrent or
residual subaortic stenosis can occur. That is a poten-
tial critical lesion requiring close follow-up and, even-
tually, reintervention (18). We surgically address
this lesion when the systolic peak gradient reaches
50 mm Hg, or with any evidence of AV insufficiency
detected by echocardiography to avoid progressive
left ventricular hypertrophy and dilatation (19). Our
incidence of postoperative complete heart block
requiring a permanent pacemaker implantation
(3.7%) is similar to those found in the literature
(12,13). Moreover, one MVR with a mechanical pro-
sthesis due to moderate to severe mitral and one
aortocoronary bypass grafting due to stenosis of a
coronary artery were performed after mechanical
AVR. However, this miscellaneous group of children,
adolescents, and GUCH is so heterogenous that it is
difficult to draw conclusions from the data. There are
so many complex patients in our series that it is not
surprising that the morbidity was 33% at latest
follow-up. Otherwise, other potential complications
after mechanical AVR such as bleeding complica-
tions, endocarditis, or rereplacement of the aortic
prosthesis due to somatic growth were not yet
observed in our series.
Anticoagulant therapy is an important issue. Most
of the reports arguing against the use of mechanical
valves mention either no anticoagulant therapy or
inadequate prophylaxis such as aspirin or aspirin and
dipyramidol. Only those studies that employ couma-
din anticoagulant therapy, maintaining an INR of
more than 2.0, report absence of thromboembolic
incidents. After AVR with a mechanical valve,
adequate antithrombotic therapy is mandatory. We
advocate maintaining an INR of 2.5–3.0 for AVR and
2.5–3.5 for MVR. The risk of thromboembolic and
bleeding complications in patients on oral anticoagu-
lant therapy for mechanical heart valves has been
thoroughly analyzed by Cannegieter et al. (20). The
linear risk of cerebral emboli was 0.68 per 100 patient
years, while the risk of peripheral emboli was much
lower at 0.03 per 100 patient years. The low incidence
of the latter is most likely due to lack of detection. In
our series, only one patient had a thromboembolic
event. This patient suffered from a stroke presumably
due to inadequate anticoagulant therapy and lives in
a care facility for children.
The echocardiographic findings showed that four
patients had mild AV regurgitation (physiological
backflow at the prosthesis) and two patients showed
a mild mitral regurgitation without hemodynamic

MECHANICAL AORTIC VALVE REPLACEMENT IN CHILDREN, ADOLESCENTS, AND GUCH 921
significance during the observation period. Transval-
vular gradients were within a clinically acceptable
range and no paravalvular leakage was found in
echocardiography. Nevertheless, we can conclude
that postoperative echocardiographic results were
within norms throughout the follow-up, although the
patient population was very inhomogeneous with
complex cardiac lesions.
Several limitations of this study merit attention.
The primary limitations to this study are its retro-
spective design and the analysis of patients from a
single institution who underwent a reoperation
during a 6-year time span. Additionally, the number
of patients is relatively small and very heterogeneous
in nature with diverse anatomy.
However, only a few studies, specifically addressing
surgical outcome of reoperations in patients who
underwent previous repair of congenital heart
defects, have been published so far. Furthermore, the
echocardiographic assessments were done by differ-
ent pediatric cardiologists, so that there might be
some measurement variability.
CONCLUSIONS
The results of the present study demonstrate that
mechanical AVR has excellent results in patients
after previous repair of congenital heart defects in
childhood, even in combination with complex con-
comitant procedures. Previous operations did not
significantly affect postoperative outcome. The vari-
able morphology and pathophysiology of the differ-
ent congenital heart defects required an individual
surgical strategy for each patient. Therefore, our
results should be interpreted with care.
Even if there is an exponential rise in the number
of children and adults with complex congenital heart
disease in an established GUCH unit in recent years,
the total number of patients still remains relatively
small. Moreover, these patients are a technical chal-
lenge and should be treated by very experienced
surgeons, pediatric cardiologists, and anesthetists in
specialized institutions.
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Artif Organs, Vol. 33, No. 11, 2009