Andersons pediatric cardiology 1472
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FIG.55.17 Surgicalaugmentationofrheumaticmitralvalve
leaflets.(A)Augmentationoftheanteriormitralvalveleaflet.(B)
Augmentationoftheposteriormitralvalveleaflet.
8.Posteriorannuloplasty,usinganautologouspericardial“band,”
potentiallyaffordsthebestlong-termoutcomes(therearemany
technicaloptions).Thisistobeusedonlyinpatientswithadilated
annulusandrelativelynormalornormalizedleafletsandsubvalvar
apparatus(Fig.55.18).
FIG.55.18
Adilatedmitralannuluswithgoodcompetenceafter
theadditionofannuloplastysutures.
MitralValveReplacement
Ifthereparativeprocedurefailsorisdeemednotfeasible,thevalveisreplaced
byamechanicalbileafletvalveorabioprosthesiscombinedwithpreservationof
someofthechordae.78Womenofchildbearingageplanningpregnancyshould
beofferedabioprostheticvalveratherthanaprostheticvalveeventhoughthe
reoperationratewillbehighandearly,necessitatingclosecardiologyfollowup.79Theriskofwarfarintothefetusorrisktothepatientonheparin-type
regimensremainshigh.80Thedevelopmentoftissue-engineeredlivingvalvesis
eagerlyawaited.81,82
AorticValveSurgery
Althoughitispossibletoachievegoodimmediateresults,attemptsattreating
ARbycuspextensionarelimitedbythelackofdurabletissue-engineered
materialtobeusedforcuspextension(seeFig.55.9).Currentlythebestresults
areobtainedbyusingtheRossoperation,whichistheonlyoperationto
guaranteelong-termsurvivalofthevalvesubstitute.83Rheumaticinvolvement
ofthepulmonaryautograftisrareandcanbepreventedbypostoperative
penicillinprophylaxis.Aorticstenosisintheyoungisrelativelyrare;repairmay
befeasibleintheearlystageswith“pure”stenosis(seeFig.55.8).
TricuspidValveSurgery
Theclinicalimportanceofchronictricuspidregurgitation(TR),presentin
approximately60%ofpatientswithsevereRHD,isunderestimated.The
regurgitationisusuallyduetoseveredilationoftheannuluswithminor
involvementofthecusps.Annuloplastyusingastripofpericardiumisvery
effectiveintreatingTR.Tricuspidstenosisislesscommonandcanbedealtwith
bylimiteddivisionofthefusedcommissurecombinedwithinsertionofartificial
chordaeandannuloplastywhennecessary.
