Andersons pediatric cardiology 1472

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 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 followup.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 are obtained by using the Ross operation, which is the only operation to 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  ... be offered a bioprosthetic valve rather than a prosthetic valve even though the reoperation rate will be high and early, necessitating close cardiology followup.79 The risk of warfarin to the fetus or risk to the patient on heparin-type