Current status of valve replacement in children

Management of valve diseases in children demands an eclectic approach by the surgeon. Whenever possible, valve function should be restored by repair rather than prosthetic replacement. Recent evidence firmly demonstrates that there are accelerated calcification and degeneration of porcine heterografts in children, especially in the aortic and mitral positions. For this reason, we reserve the use of heterograft prostheses for the right atrioventricular position and for conduits from the right ventricle to the pulmonary artery. Such patients are observed carefully for signs of valve degeneration. Long-term followup of the Starr-Edwards prosthesis in children demonstrates excellent durability and a thromboembolic rate that is equal to or lower than that found in adult patients. Hemodynamic properties of the Starr-Edwards valve are adequate even in the smallest size used in infants and have allowed children to reach early adolescence at which time valve re-replacement with an adult-sized prosthesis is possible. Intermediate-term experience with the Bjork-Shiley valve in children has also been favorable. At present we continue to use systemic anticoagulation with warfarin in all children with mechanical prostheses.