Andersons pediatric cardiology 1472

55.17 Surgical augmentation of rheumatic mitral valve leaflets.. A Augmentation of the anterior mitral valve leaflet.. B Augmentation of the posterior mitral valve leaflet.. This is to

FIG 55.17 Surgical augmentation of rheumatic mitral valve leaflets (A) Augmentation of the anterior mitral valve leaflet (B)

Augmentation of the posterior mitral valve leaflet.

8 Posterior annuloplasty, using an autologous pericardial “band,” potentially affords the best long-term outcomes (there are many technical options) This is to be used only in patients with a dilated annulus and relatively normal or normalized leaflets and subvalvar apparatus (Fig 55.18)

FIG 55.18 A dilated mitral annulus with good competence after

the addition of annuloplasty sutures.

Mitral Valve Replacement

If the reparative procedure fails or is deemed not feasible, the valve is replaced

by a mechanical bileaflet valve or a bioprosthesis combined with preservation of some of the chordae.78 Women of childbearing age planning pregnancy should

be offered a bioprosthetic valve rather than a prosthetic valve even though the

reoperation rate will be high and early, necessitating close cardiology follow-up.79 The risk of warfarin to the fetus or risk to the patient on heparin-type

regimens remains high.80 The development of tissue-engineered living valves is eagerly awaited.81,82

Aortic Valve Surgery

Although it is possible to achieve good immediate results, attempts at treating

AR by cusp extension are limited by the lack of durable tissue-engineered

material to be used for cusp extension (see Fig 55.9) Currently the best results

guarantee long-term survival of the valve substitute.83 Rheumatic involvement

of the pulmonary autograft is rare and can be prevented by postoperative

penicillin prophylaxis Aortic stenosis in the young is relatively rare; repair may

be feasible in the early stages with “pure” stenosis (see Fig 55.8)

Tricuspid Valve Surgery

The clinical importance of chronic tricuspid regurgitation (TR), present in

approximately 60% of patients with severe RHD, is underestimated The

regurgitation is usually due to severe dilation of the annulus with minor

involvement of the cusps Annuloplasty using a strip of pericardium is very effective in treating TR Tricuspid stenosis is less common and can be dealt with

by limited division of the fused commissure combined with insertion of artificial chordae and annuloplasty when necessary