Andersons pediatric cardiology 1469

SurgeryforRheumaticValveDisease
AlthoughARFaffectsmanyorgans,themainburdenofthedisease,intermsof
morbidityandmortality,stemsfromchronicheartvalvedisease.72The
irreversibledamagetothevalvescanbetreatedbyonlymechanicalmethods
performedbypercutaneousinterventionsinasmallnumberorcardiacsurgery
forthemajority.
Asdescribedearlier,theindicationsforandtimingofoperationareguidedby
theseverityofsymptoms,clinicalexamination,andechocardiographic
assessment.Cardiaccatheterizationisseldomrequiredtomeasurecardiacoutput
andpulmonaryvascularresistance.TheAHAandEuropeanSocietyof
Cardiologyguidelines55,73fortimingoperationsinadultsaresummarizedin
Table55.4andsupplementedbypediatric-specificrecommendationfromthe
NewZealandnationalARF/RHDguidelines.54
Table55.4
IndicationsforValveIntervention
ESC/EACTS73
AR

SeveresymptomaticAR
SevereasymptomaticARif:
■LVEF<50%
■LVEDD>70mm
■LVESD>50mm
■LVESDI>25mm/m2
■Undergoingothersurgery
AS
SeveresymptomaticAS:
■MeanPG>40mmHg
■Peakvelocity>4m/s
Lowflow,lowgradientsevere
AS(aftercarefulassessment)

Severeasymptomaticif:
■LVEF<50%
■Abnormalexercisetest
■Veryseverestenosis
■Severecalcification
■ElevatedBNP
■SeverePHTN
Undergoingothersurgery
MR
SeveresymptomaticMR
whenLVEF>30%
SevereasymptomaticMRif:

NewZealand
Pediatric54
Additions:
Additions:
ProgressivesevereLVdilationLVEDD>65mmiflow LVESVzsurgicalrisk
score>4

AHA/ACC55

Additions:
■Low-dosedobutamineincreasesseverity
■Restingvalvearea<1cm2
■SVI<35mL/m2
■AVAI<0.6cm2
■Increasevelocity>0.3m/sec/year
■ModerateASundergoingsurgeryforothercondition

Additions:
■Severeasymptomaticif:
■LVEF30%–60%

Additions:
LVESVzscore>2.5


■LVESD>45mm
■LVEF<60%
■WithAF
■WithSPAP>50mmHgatrest
■Durable,low-riskrepairlikely
■Flailleaflet
■SignificantLAdilation
■LVdysfunctionifrepairhigh
likelyandlowcomorbidities
MS
SevereMS(MVA<1.5cm2)
PMCpreferredif:
■Favorablevalvecharacteristics
andnocontraindications
■High-risksurgery
■HighTErisk
■Needformajornoncardiac
surgery
■Pregnancy
■PAP>50%
Surgeryifvalvenotsuitable
forPMC

■LVESD>40mm
■SevereMRrepairisconsideredwithLVEF<30%
■ModerateMRifundergoingsurgeryforother
indication
Emphasisonpreferenceofrepairoverreplacement
Preferenceofrepairinrheumaticetiologyif
durabilityisexpectedoranticoagulation
questionable
Additions:
Surgeryif:
■Undergoingothersurgery
■ExcisionofLAAwhenrecurrentembolicevents
despiteadequateanticoagulation

ACC,AmericanCollegeofCardiology;AF,atrialfibrillation;AHA,AmericanHeartAssociation;
AR,aorticregurgitation;AS,aorticstenosis;AVAI,aorticvalveareaindex;BNP,brainnatriuretic
protein;EACTS,EuropeanAssociationforCardio-ThoracicSurgery;ESC,EuropeanSocietyof
Cardiology;LA,leftatrium;LAA,leftatrialappendage;LV,leftventricle,LVEDD,leftventricular
end-diastolicdimension;LVESDI,leftventricularend-systolicdimensionindex;LVEF,left
ventricularejectionfraction;LVESD,leftventricularend-systolicdimension;LVESV,leftventricular
end-systolicvolume;MR,mitralregurgitation;MS,mitralstenosis;MVA,mitralvalvearea;PAP,
pulmonaryarterypressure;PG,pressuregradient;PHTN,pulmonaryhypertension;PMC,
percutaneousmitralcommissurotomy;SPAP,systolicpulmonaryarterypressure;SVI,stroke
volumeindex;TE,thromboembolism.

MitralValveOperations
RHDmayaffectallcomponentsoftheMVapparatus;theannulus,leaflets,and
subvalvarapparatus.Untilrecently,themostcommonlyperformedmitral
operationwasvalvereplacement,reachingupto80%ormore.74Thereis

growingconcernovertheveryhighcomplicationratesassociatedwithMV
replacementinRHD(Fig.55.12).50,75Whentechnicallyfeasible,theideal
operationforthesepatientsshouldbeMVrepair.