Commentary: Revisiting the Question: Should We Avoid Valve Replacement in Children?

Abstract

See Article page 90.

Valve replacement in very young children with valvular disease, regardless of valve position, remains a last resort for congenital cardiac surgeons because of several well-recognized limitations. These include technical constraints related to small annular dimensions, the requirement for lifelong anticoagulation, and the inevitability of patient–prosthesis mismatch as somatic growth continues. Risk factors for early mortality and adverse events after infant mitral valve replacement have been repeatedly reported, with younger age (particularly under 2 years), small body size, and prosthesis–patient size discrepancy consistently associated with increased early risk [1-4].

With respect to mitral valve replacement specifically, additional concerns extend beyond the general limitations described above. Long-term outcomes after mitral valve replacement in infants and children have been troubling, with substantial rates of late mortality, valve-related complications, and the need for repeated valve replacement during follow-up [2-6]. These observations have reinforced the long-standing preference for mitral valve repair whenever it is technically feasible.

More recently, however, several studies have questioned a purely “replacement-avoidance” strategy for systemic atrioventricular valve disease, particularly in complex congenital settings where durable repair is unlikely. Although systemic atrioventricular valve replacement in single-ventricle physiology differs fundamentally from mitral valve replacement in biventricular circulation, the latter may require even more careful consideration of annular size and growth-related mismatch. Lim et al. [7], posed the question, “Should we avoid valve replacement?” in the context of functional single-ventricle physiology, and their work, together with related institutional experiences, supports a more balanced decision-making framework rather than reflexive avoidance of replacement [8,9].

The current report by Park et al. [10] offers important evidence that valve replacement performed at a very young age should no longer be regarded solely as a marker predicting poor outcomes. Notably, the causes of mortality in their cohort were not necessarily attributable to the mechanical prosthesis itself, suggesting that outcomes may be driven more by underlying disease complexity, the timing of mitral valve replacement, or associated comorbidities than by valve replacement per se.

A more detailed description of time-dependent changes preceding redo mitral valve replacement, such as transprosthetic mitral gradients, the progression of pulmonary hypertension, or changes in left atrial dimensions and compliance, could have helped readers better understand the physiological triggers for reintervention. Such information might also inform practical thresholds for the optimal timing of redo mitral valve replacement.

Despite the limitations acknowledged by the authors, this study adds meaningful support to the view that, in pediatric patients for whom repair is unlikely to ensure durable long-term results, surgeons should not hesitate to proceed with mechanical valve replacement, even in very small children. This approach is appropriate provided that decision-making is individualized and that longitudinal reintervention is anticipated as an integral component of the growth-related treatment pathway.