Keywords: children; valve disease; surgery Heart valve disease in children is commonly associated with congenital malformations, infective endocarditis, and rheumatically induced valve stenosis and insufficiency. Although valvuloplasty is used for most of the heart valve diseases in children, valve replacement is still required for children with heart valve diseases that are difficult to be corrected by valvuloplasty or fail to be treated by valvuloplasty [1]. Due to the high complications and mortality of heart valve replacement in children, the need for revalve replacement with growth and development after placement of smaller prosthetic valves, and the difficulty of anticoagulation management, there is currently more controversy about the surgical treatment of valve disease in children [2]. From January 2003 to January 2008, we performed heart valve replacement surgery in 12 children under 14 years of age with satisfactory results. They are reported below. Peng Wanfu, Department of Cardiac Surgery, Affiliated Hospital of Guizhou Medical University Clinical Data 1. General Data There were 12 cases in this group, including 8 males and 4 females; the youngest age was 8 years old, the oldest age was 14 years old, and the average age was 11 years old. One case of congenital heart disease was congenital septal defect and arteriovenous ductus arteriosus, combined with severe aortic valve insufficiency, and heart function grade III; 6 cases of infective endocarditis were infected with aortic valve superfluous formation, causing severe aortic valve insufficiency, and heart function grade IV; 5 cases of rheumatic heart valve disease were severe mitral valve stenosis, and heart function grade IV. The mitral valve was replaced in 5 cases and the aortic valve was replaced in 7 cases. 10 cases used imported double leaflet valves and 2 cases used domestic lateral tilting disc valves. All cases were treated with warfarin for anticoagulation after surgery, and no complications such as thromboembolism and bleeding occurred, and cardiac function was grade I-II. The follow-up period was 10 months~5 years, and there was no one case of death. 1. Methods After good preoperative preparation, all 12 cases were opened with a median incision under general anesthesia, and extracorporeal circulation was routinely established. In the children with congenital heart disease, the ventricular septal defect was repaired and the arterial catheter ligation was performed first, the aorta was opened, and the heart automatically resumed beating, but the heart rate slowed down, the blood pressure dropped, the left ventricle was filled and the pressure was high, and the extracorporeal circulation was reestablished, the aorta was cut, and the right coronary valve was seen to be poorly developed and closed mainly, the own valve was removed, and the 19# Carbomedics annulus was intermittently sutured with mattress sutures. The aortic valve was opened again, and the heart was automatically resuscitated and stopped successfully. One of them had a perivalvular abscess. The abscess was completely removed and the valve was disinfected twice with iodophor gauze balls, and the valve was removed. In children with rheumatic heart disease, the left atrium of the left ventricle was enlarged intraoperatively, and the mitral valve leaflets were thickened and curled to varying degrees, with stenosis predominating, and no thrombus was seen in the left atrium. The resected valves were routinely sent for pathological examination. 3. Results There were no surgical deaths in this group, and the recovery was smooth with the successful discontinuation of ventilator and removal of tracheal intubation 5~18 hours after surgery and dobutamine assistance for 24~72 hours. Only one case had a transient IIIo AV block in the early postoperative period, which was maintained with isoproterenol for 2 days, and the heart rate was controlled between 120 and 140 beats/min. All of them were treated with anticoagulation therapy with warfarin after the operation, and the follow-up period was 10 months to 5 years without complications such as thromboembolism and bleeding, and the review echocardiogram showed good valve switching and the cardiac function was grade I-II. The treatment of heart valve disease in children is a difficult problem for cardiac surgeons. Since the heart valves in children are still in the developmental stage, the first consideration should be to perform valvuloplasty and avoid valve replacement as much as possible. However, valve replacement is still an effective treatment for valves that are not suitable for valvuloplasty or have failed valvuloplasty, valves with significant thickening and curling contracture in rheumatic valve disease, and valves with severe damage beyond repair in infective endocarditis [3]. Heart valve replacement in children should be strictly controlled for surgical indications. For heart valve lesions in children, medical treatment or valvuloplasty should be used first as much as possible to prepare for later valve replacement surgery. However, for those who are not suitable for valvuloplasty or failed valvuloplasty, especially for those with rheumatic valve disease with significant valve thickening and curl contracture, and those with infective endocarditis with severe valve damage that cannot be repaired, valve replacement surgery is still needed to save the child’s life. In this group, 12 cases with preoperative ultrasound showing poor valve quality, all with severe stenosis or incomplete closure and cardiac function of grade III-IV, were treated with valve replacement surgery under general anesthesia with extracorporeal circulation, with satisfactory results and no death. Early mortality after valve replacement in children is higher than in adults, with a mortality rate of 5% to 35%, and the surgical risk is closely related to the age of the child and the combined congenital anomalies [3]. It has been shown that the morbidity and mortality rate of heart valve replacement in children is significantly higher than that of adults, and the younger the age, the higher the morbidity and mortality rate [4]. Selection of the appropriate type of valve is extremely important in pediatric valve replacement surgery. Since children’s valves are still growing and developing, placing a valve that is too small for their development may result in relative stenosis and require reoperation with a larger prosthetic valve. Children with valve replacement should try to choose a slightly larger prosthetic valve so that it can accommodate later growth and development and delay the secondary surgery. In older children, most larger prosthetic valves can be placed because valve lesions often lead to significant heart enlargement. In this group of older children with significantly enlarged hearts, adult-sized prosthetic valves were successfully placed. Therefore, in pediatric patients with significantly enlarged hearts, placement of a suitable adult prosthetic valve can ensure their postoperative growth and developmental needs and delay or reduce the chance of a second operation. In the choice of mechanical and biologic valves, although biologic valves do not require constant postoperative anticoagulation, they have now been abandoned by most clinicians in children because of their early calcification and decline. Currently, a double-lobe mechanical valve is widely used, which has the advantages of a large effective opening area, excellent hemodynamics, a small range of leaflet motion, and less susceptibility to dyskinesia and thrombus formation [5]. The choice of prosthetic valve for children is based on the following factors: 1 it must have a long service life; 2 it must meet the growing needs of the child; 3 it will not produce intracardiac flow obstruction; 4 it will not damage adjacent cardiac structures; 5 it will minimize the risk of postoperative thrombosis; and 6 it will avoid infection of the valve as much as possible [6]. The difficulty with heart valve replacement in children is the smaller annulus but the need to place a larger type of prosthetic valve, the aim of which is to avoid reoperation and to meet the needs of valve growth and development in children. In this group of children, interrupted mattress sutures with spacers were used, which were gentle and minimized damage to the myocardium. For children with infective endocarditis, routine high-dose postoperative antibiotic therapy was administered for at least 1 month, and echocardiograms were reviewed regularly. There is no uniformity regarding anticoagulation therapy after valve replacement in children. The common principle is to minimize complications such as coagulation or bleeding. Zhu Hongyu et al. concluded in pediatric valve replacement that the application of low-intensity anticoagulation therapy after mechanical valve replacement is safe and reliable, and it is advisable to choose mechanical valves whenever possible [7]. Although there are also individual reports of anticoagulation using aspirin, it is still common practice to apply long-term anticoagulation after warfarin surgery. Currently, the standard of anticoagulation in foreign countries is mostly controlled with an “international normalized ratio (INR)” in the range of 2.5 to 3.5, while in China it is usually reported to be low, but with few complications [8]. In our group of children, anticoagulation with warfarin was started on the first postoperative day, and we maintained the antithrombin time at 1.5-2 times normal, both with a postoperative prothrombin time of 18-24 seconds, and no complications such as thrombosis or bleeding occurred. According to our clinical experience, frequent adjustments should be made after valve replacement in children, and we believe that it is best to review the valve once a month for the first six months after surgery and adjust the dosage of warfarin according to the results of the review, and preferably once every 3 months thereafter, so as to reduce the occurrence of complications. Valve replacement surgery for children with severe heart valve disease can, on the one hand, save the child’s life, improve cardiac function, and enhance quality of life. On the other hand, it can provide conditions for other surgeries or secondary surgeries, expand the scope of cardiac surgery, improve the quality of medical care, and can obtain good social benefits. References [1] Huang R M, Luo W J, Chen S H, et al. Experience of mechanical valve replacement surgery in children with heart valve disease. Journal of Central South University, 2007, (1):153-155. [2] Wang KX, Lou Y, Guo YH, et al. Techniques and outcomes of heart valve replacement surgery in children. Medical Information Surgical Branch, 2006,19(3):14-16. [3] Lai YQ, Lai YH, Han R, et al. Heart valve replacement surgery in children and its efficacy. Chinese Journal of Thoracic and Cardiovascular Surgery, 2004,6(20):136-138. [4] Pan You-Min, Pan Tie-Cheng, Zhao Jin-Ping, et al. Heart valve replacement in children. Chinese Journal of Pediatric Surgery,2006,27(2):69-71. [5] Long Chaozhong, Zhou Xinmin, Hu Jianguo, et al. Analysis of 105 cases of heart valve replacement in children. Chinese Journal of Medicine,2005,85(36):1849-1852. [6] Wu CHQ, Liang SW, Li JS. Heart valve replacement in children. Journal of Clinical Surgery, 1999,7(4):199-200. [7] Zhu Hongyu, Wang Zengwei, Fei Chengjian, et al. Valve replacement in children. Chinese Journal of Surgery, 1996,34(7):433-435. [8] Li, Chen, Zhang-Gen, Jia, Bing, et al. Heart valve replacement in children. Fudan Journal (Medical)