Concept of an expandable cardiac valve for surgical implantation in infants and children

Background: Options for cardiac valve replacement in children are limited to fixed-diameter prostheses that do not accommodate for somatic growth. An externally stented bovine jugular vein graft has been modified for surgical valve replacement in pediatric patients, with the intention of subsequent valve expansion in the catheterization laboratory as the child grows. Methods: Pediatric patients at a single institution who underwent surgical implantation of an expandable bovine jugular vein valve between 2010 and 2014 were reviewed retrospectively. Forty-two patients underwent implantation at median age of 10 months (range, 3 weeks to 5.8 years) in aortic, mitral, pulmonary, or tricuspid positions. Numerous techniques for valve modification and implantation were used. Results: The valve was competent with low gradient acutely postoperatively in all patients. Eight patients experienced central or paravalvular deterioration, and 7 required reoperation for valve-related adverse outcomes. Twenty patients underwent at least one previous valve repair or replacement. Twenty patients underwent 32 episodes of catheter-based balloon expansion of the valve, exhibiting a significant decrease in median gradient from 12 mm Hg to 8 mm Hg (P<.001) with no significant increase in grade of regurgitation. At 12 months after implantation, Kaplan-Meier analysis indicated that 88% would be expected to be free from reoperation (95% confidence interval, 78%-98%). A total of 6 deaths occurred, 3 before discharge and 3 late. Conclusions: A surgically implanted externally reinforced bovine jugular vein demonstrates acceptable short-term function and is amenable to catheter-based enlargement as the child grows. Modification of valve design and implantation techniques are necessary to reduce perivalvular complications.