Surgical repair of congenital mitral valve malformations
Reparación quirúrgica de las malformaciones congénitas de la válvula mitral
Pedro Curi-Curia, Samuel Ramírez-Marroquínb, Jorge Cervantes-Salazarc, Mauricio Souléa, Julio Erdmengerd, Juan Calderón-Colmeneroe
a Cirujano Cardiovascular Pediátrico.
b Jefe del Departamento de Cirugía Cardiaca Pediátrica y de Cardiopatías Congénitas.
c Subjefe del Departamento de Cirugía Cardiaca Pediátrica y de Cardiopatías Congénitas.
d Médico Ecocardiografista Pediátrico. Departamento de Cardiología Pediátrica.
e Subjefe del Departamento de Cardiología Pediátrica. Instituto Nacional de Cardiología Ignacio Chávez
Read
15841
Timeswas read the article
1337
Total PDF
14504
Total HTML
Share statistics
array:20 [ "pii" => "X1405994010534009" "issn" => "14059940" "estado" => "S300" "fechaPublicacion" => "2010-04-01" "documento" => "article" "crossmark" => 0 "licencia" => "http://www.elsevier.com/open-access/userlicense/1.0/" "subdocumento" => "fla" "cita" => "Arch Cardiol Mex. 2010;80:87-94" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 8223 "formatos" => array:3 [ "EPUB" => 60 "HTML" => 7529 "PDF" => 634 ] ] "itemSiguiente" => array:16 [ "pii" => "X1405994010534017" "issn" => "14059940" "estado" => "S300" "fechaPublicacion" => "2010-04-01" "documento" => "article" "crossmark" => 0 "licencia" => "http://www.elsevier.com/open-access/userlicense/1.0/" "subdocumento" => "fla" "cita" => "Arch Cardiol Mex. 2010;80:95-9" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 19566 "formatos" => array:3 [ "EPUB" => 44 "HTML" => 16752 "PDF" => 2770 ] ] "es" => array:11 [ "idiomaDefecto" => true "titulo" => "Complicaciones del implante de marcapaso definitivo. ¿Un evento operador dependiente? Análisis de 743 pacientes consecutivos" "tienePdf" => "es" "tieneTextoCompleto" => "es" "tieneResumen" => array:2 [ 0 => "es" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "95" "paginaFinal" => "99" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Complications of permanent pacemaker. Event operator dependent? Analysis of 743 consecutive patients" ] ] "contieneResumen" => array:2 [ "es" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Francisco J. Femenía, Mauricio Arce, Fernando Peñafort, Martín Arrieta, Daniel Gutiérrez." "autores" => array:5 [ 0 => array:2 [ "nombre" => "Francisco J." "apellidos" => "Femenía" ] 1 => array:2 [ "nombre" => "Mauricio" "apellidos" => "Arce" ] 2 => array:2 [ "nombre" => "Fernando" "apellidos" => "Peñafort" ] 3 => array:2 [ "nombre" => "Martín" "apellidos" => "Arrieta" ] 4 => array:2 [ "nombre" => "Daniel" "apellidos" => "Gutiérrez." ] ] ] ] ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X1405994010534017?idApp=UINPBA00004N" "url" => "/14059940/0000008000000002/v0_201307091127/X1405994010534017/v0_201307091128/es/main.assets" ] "itemAnterior" => array:16 [ "pii" => "X1405994010533998" "issn" => "14059940" "estado" => "S300" "fechaPublicacion" => "2010-04-01" "documento" => "article" "crossmark" => 0 "licencia" => "http://www.elsevier.com/open-access/userlicense/1.0/" "subdocumento" => "fla" "cita" => "Arch Cardiol Mex. 2010;80:79-86" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 4968 "formatos" => array:3 [ "EPUB" => 48 "HTML" => 4140 "PDF" => 780 ] ] "en" => array:12 [ "idiomaDefecto" => true "titulo" => "Functional and structural regeneration in the axolotl heart ( <span class="elsevierStyleItalic">Ambystoma mexicanum</span>) after partial ventricular amputation" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "79" "paginaFinal" => "86" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Regeneración funcional y estructural del corazón de axolotl ( <span class="elsevierStyleItalic">Ambystoma mexicanum</span>) después de amputación parcial del ventrículo" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig1" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "293v80n02-13153399fig1.jpg" "Alto" => 1341 "Ancho" => 845 "Tamanyo" => 131723 ] ] "descripcion" => array:1 [ "en" => "Representative traces of spontaneously developed contractile activity of the whole heart of adult Ambystoma mexicanum, in isolated organ assays. Traces correspond to control (a) and to day one (b), five (c), and 30 and 90 (d) after partial ventricular resection. Hearts were maintained in amphibian Ringer, pH 7.8, and the contractile activity was simultaneously recorded for ventricle and atrium at 16+1°C. Upper panel shows a complete cycle of contractile activity and criteria of measurement of the ventricular and atrium tensions. A= atrium, V= ventricle, T= tension." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Agustina Cano-Martínez, Alvaro Vargas-González, Verónica Guarner-Lans, Esteban Prado-Zayago, Martha León-Olea, Betzabé Nieto-Lima" "autores" => array:6 [ 0 => array:2 [ "nombre" => "Agustina" "apellidos" => "Cano-Martínez" ] 1 => array:2 [ "nombre" => "Alvaro" "apellidos" => "Vargas-González" ] 2 => array:2 [ "nombre" => "Verónica" "apellidos" => "Guarner-Lans" ] 3 => array:2 [ "nombre" => "Esteban" "apellidos" => "Prado-Zayago" ] 4 => array:2 [ "nombre" => "Martha" "apellidos" => "León-Olea" ] 5 => array:2 [ "nombre" => "Betzabé" "apellidos" => "Nieto-Lima" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X1405994010533998?idApp=UINPBA00004N" "url" => "/14059940/0000008000000002/v0_201307091127/X1405994010533998/v0_201307091127/en/main.assets" ] "en" => array:15 [ "idiomaDefecto" => true "titulo" => "Surgical repair of congenital mitral valve malformations" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "87" "paginaFinal" => "94" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "Pedro Curi-Curi, Samuel Ramírez-Marroquín, Jorge Cervantes-Salazar, Mauricio Soulé, Julio Erdmenger, Juan Calderón-Colmenero" "autores" => array:6 [ 0 => array:3 [ "nombre" => "Pedro" "apellidos" => "Curi-Curi" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] 1 => array:3 [ "nombre" => "Samuel" "apellidos" => "Ramírez-Marroquín" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "affb" ] ] ] 2 => array:3 [ "nombre" => "Jorge" "apellidos" => "Cervantes-Salazar" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "affc" ] ] ] 3 => array:3 [ "nombre" => "Mauricio" "apellidos" => "Soulé" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] 4 => array:3 [ "nombre" => "Julio" "apellidos" => "Erdmenger" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "affd" ] ] ] 5 => array:3 [ "nombre" => "Juan" "apellidos" => "Calderón-Colmenero" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">e</span>" "identificador" => "affe" ] ] ] ] "afiliaciones" => array:5 [ 0 => array:3 [ "entidad" => "Cirujano Cardiovascular Pediátrico." "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] 1 => array:3 [ "entidad" => "Jefe del Departamento de Cirugía Cardiaca Pediátrica y de Cardiopatías Congénitas." "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "affb" ] 2 => array:3 [ "entidad" => "Subjefe del Departamento de Cirugía Cardiaca Pediátrica y de Cardiopatías Congénitas." "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "affc" ] 3 => array:3 [ "entidad" => "Médico Ecocardiografista Pediátrico. Departamento de Cardiología Pediátrica." "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "affd" ] 4 => array:3 [ "entidad" => "Subjefe del Departamento de Cardiología Pediátrica. Instituto Nacional de Cardiología Ignacio Chávez " "etiqueta" => "<span class="elsevierStyleSup">e</span>" "identificador" => "affe" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Reparación quirúrgica de las malformaciones congénitas de la válvula mitral" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig1" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "293v80n02-13153400fig1.jpg" "Alto" => 1100 "Ancho" => 1020 "Tamanyo" => 171164 ] ] "descripcion" => array:1 [ "en" => "Schematic diagrams of surgical mitral valve repair techniques and number of cases." ] ] ] "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">Introduction</span></p><p class="elsevierStylePara">The mitral valve is a complex morphologic and functional apparatus formed by the annulus, leaflet valves, tendi-neal chords, papillary muscles and left ventricular wall.<span class="elsevierStyleSup">1</span> Pathologic lesions that affect one or more of these components result in a valvular stenosis and/or insufficiency.<span class="elsevierStyleSup">2</span></p><p class="elsevierStylePara">Appropriate diagnosis of the valvular malformation and the assessment of its severity by transthoracic echo-cardiography have been complemented by transesophageal echocardiography which improve knowledge of production mechanisms of the mitral lesions. This, in fact, has contributed to the development of the current interest in surgical repair techniques as an alternative to mitral valve prosthetic replacement.<span class="elsevierStyleSup">3</span></p><p class="elsevierStylePara">The advantages of mitral valve surgical repair techniques over mitral valve prosthetic replacement in adults has been widely accepted.<span class="elsevierStyleSup">4</span> However, the development of these techniques in pediatric patients has been slow because of the great variety in the presentation of congenital mitral valve malformations and the still unknown effect of growth over the complex mitral valve apparatus.<span class="elsevierStyleSup">5-16</span> Additionally, experience in surgery of mitral valve malformations in Mexico is poor and limited to stenotic lesions.<span class="elsevierStyleSup">17</span> Congenital insufficiency, which is the most frequent mitral valve lesion, is not well described in our country.</p><p class="elsevierStylePara">The objective of this study is to review, the early and mid-term results in the surgical repair of congenital mitral valve malformations at our institution. </p><p class="elsevierStylePara"><span class="elsevierStyleBold">Methods</span></p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Group of study.</span> Between January 2002 and May 2007, we retrospectively studied all pediatric patients in whom surgical valve repair was performed because of mitral congenital malformation in the National Institute of Cardiology Ignacio Chavez. </p><p class="elsevierStylePara">From a total of 27 patients with surgical mitral valve repair, we excluded those with acquired mitral valve disease, cyanotic congenital heart disease, atrioventricular septal defect, L-transposition of great arteries, single ventricle, Marfan syndrome, and anomalous left coronary origin from pulmonary artery (ALCAPA). We included in our study 14 patients with congenital mitral valve malformations.</p><p class="elsevierStylePara">Preoperatory echocardiography diagnosis of the mitral valve malformations was performed in all cases in order to establish the type of valvular lesions according to the pathophysiological Carpentier's classification.<span class="elsevierStyleSup">8</span> In those patients with complex mitral valve lesions, the predominant lesion was used for their classification. </p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Surgical technique:</span> Surgical approach for all patients was through a median sternotomy. Cardiopulmonary bypass was established by aortic and bicaval cannulation. After aortic cross clamp, we used moderate hypothermia and antegrade blood cardioplegia for myocardical protection. Only in one case we used cristaloid antegrade and retrograde cardioplegia. The mitral valve was approached by left atriotomy in all cases, and several mitral surgical repair techniques were used for every patient. </p><p class="elsevierStylePara"><span class="elsevierStyleBold">Figure 1</span> describes the surgical techniques used for mitral valve repair, and <span class="elsevierStyleBold">Figure 2</span> the associated procedures. After weaning of cardiopulmonary bypass was completed, and before the decanulation time, we rutinarily performed an intraoperatory transesophageal echocardiography to evaluate mitral competence after valve repair.</p><p class="elsevierStylePara"><img src="293v80n02-13153400fig1.jpg" alt="Figure 1. Schematic diagrams of surgical mitral valve repair techniques and number of cases."></img></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Figure 1. </span>Schematic diagrams of surgical mitral valve repair techniques and number of cases.</p><p class="elsevierStylePara"><img src="293v80n02-13153400fig6.jpg" alt="Figure 2. Number and percentage of associated surgical procedures."></img></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Figure 2. </span>Number and percentage of associated surgical procedures.</p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Follow-up strategy:</span> We carried out a clinical and echocardiographic early and mid-term follow-up. All survivors had a clinical follow-up evaluation of their functional class stratification using the New York Heart Association classification (NYHA) for children and young patients,<span class="elsevierStyleSup">18</span> and the modified Ross classification for neonates and infants.<span class="elsevierStyleSup">19</span> Echocardiographic follow-up was obtained in all of the symptomatic patients and in 50% of the asymptomatic ones. The degree of mitral echocardiographic insufficiency was estimated by a semiquantitative method based in the maximum lenght and width of the regurgitant jet in relation to the left atrium as follows: 0 = none, without regurgitation; 1 = mild, regurgitant jet less than 1/3 the lenght and width of the left atrium; 2 = moderate, regurgitant jet between 1/3 and <span class="elsevierStyleSup">1</span>/2 of this lenght and width; 3 = moderate to severe, regurgitant jet between <span class="elsevierStyleSup">1</span>/2 and 2/3; and 4 = severe, regurgitant jet larger than 2/3 of the lenght and width of the left atrium. We also evaluated the regurgitant jet direction. Degree of stenosis was minimum, moderate or severe depending on the transvalvular mitral valve gradient and the area of the orifice of this valve in relation to the patient´s age and weight.<span class="elsevierStyleSup">20</span></p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Statistical analysis:</span> Information was obtained from our institutional clinical database, stored in an electronic Excell page and processed with a SPSS statistical software. Numeric results are presented as a mean, variability ranges, and percentages in relation to the risk population. Overall survival rate and freedom from reoperation for mitral valve prosthetic replacement survival rate were calculated using the Kaplan - Meier method.</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Results</span></p><p class="elsevierStylePara">Clinical features of the 14 patients (eight males and six females) of our study are summarized in <span class="elsevierStyleBold">Table 1.</span> Age ranged between one month and 16 years (mean 4.4 years), with a mean weight of 13.8 kg (range, 3.5 to 50 kg), mean length of 92 cm (range, 50 to 155 cm), and body surface area of 0.6 m<span class="elsevierStyleSup">2</span> (range, 0.22 to 1.46 m<span class="elsevierStyleSup">2</span>). </p><p class="elsevierStylePara"><img src="293v80n02-13153400fig2.jpg" alt="Table 1. Clinical features of the studied cases. CML= Complex mitral lesion, >= Predominance of, St.= stenosis, Insuf.= insufficiency."></img></p><p class="elsevierStylePara">Twelve (86%) of these patients did not have previous cardiovascular surgical or interventional procedures. Two cases had an associated aortic coartation that was treated by surgical coartectomy in one of them (7%). In the other case (7%) an interventional balloon dilatation of the coartated segment was performed. Associated congenital malformations occurred in eight patients (57%), as shown in <span class="elsevierStyleBold">Table 2</span>. </p><p class="elsevierStylePara"><img src="293v80n02-13153400fig3.jpg" alt="Table 2. Associated congenital malformations. "></img></p><p class="elsevierStylePara">Sinus rhythm was present in all patients at the time of admission to the hospital, and in two of them (14%) the electrocardiogram (ECG) showed a right bundle branch block. Half of the patients were in heart failure preoperatively, but only one (7%) required inotropic support before surgery. None of the patients needed mechanic ventilation, and all of them received an appropriate preoperatory medical treatment in order to arrive to surgery in the best hemodynamic conditions as possible. </p><p class="elsevierStylePara">Mitral valve repair was possible in all of the cases, with a mean cardiopulmonary bypass time of 96min (range, 44 to 174min), aortic cross-clamp of 61 min (range, 18 to 134min) and 29°C hypothermia (range, 25 to 32°C). Mitral predominant lesion was incompetence in 11 patients (79%) and stenosis in three (21%). <span class="elsevierStyleBold">Table 3</span> shows the groups of patients according to Carpentier's pathophysiological classification.<span class="elsevierStyleSup">8</span></p><p class="elsevierStylePara"><img src="293v80n02-13153400fig4.jpg" alt="Table 3. Patient groups according to Carpentier's pathophysiological classification."></img></p><p class="elsevierStylePara">The surgical techniques used were mitral annuloplasty, papillary muscles fenestration, open bilateral commisurotomy, valve cleft closure and supravalvular mitral membrane resection. Less frequently used techniques were anterior valve leaflet repair (with bovine pericar-dial patch enlargement, tendineal chords resuspension or reduction) and quadrangular posterior leaflet valve resection. We used bovine pericardium for all mitral annuloplasties, except in one case that received a rigid Carpen-tier hemiannulus. Concurrent repair of associated lesions included ductus closure in three cases, ventricular septal defect closure in two cases, and atrial septal defect closure in two cases. Additionally, we performed an aortic valve replacement in the oldest patient of our series (16 years) who had a severe regurgitant congenitally bicuspid aortic valve in association with a moderate mitral valve insufficiency (<span class="elsevierStyleBold">Figure 2</span>). </p><p class="elsevierStylePara">There were no operative complications and operative morbidity rate was 77%. Morbidity events are described in <span class="elsevierStyleBold">Table 4</span>. There was only one early death (operative mortality of 7%), from hypovolemic shock from a subclavian artery lesion due to a re-introduction of a central venous catheter. </p><p class="elsevierStylePara"><img src="293v80n02-13153400fig5.jpg" alt="Table 4. Operative morbidity causes."></img></p><p class="elsevierStylePara">The 13 survivors had a mean postoperative hospitalization stay of 15.5 days (range, 4 to 56 days), and 3.7 days (range, 1 to 11 days) in the Intensive Care Unit, with a mean mechanic ventilation time of 4 days (range, 2 hours to 20 days). There were four patients who needed reoperation during the early postoperative period (30.7%), with a mean of 1.2 (range, 1 to 2) reoperations per patient with mean time of 11.5 days (range, 1 to 28 days) after the first surgery. In two cases, reoperations were needed for extracardiac reasons (tracheostomy with gastrostomy, and left superior lung abscess drainage). In another case, reoperation was to perform a pericardial window because of pericardial effusion. Finally, two of the reoperations were for mitral valve prosthetic replacement because of early failure of the mitral valve repair. The first patient was a six month male infant with a mitral supravalvular membrane, a dysplastic stenotic mitral valve due to tendineal chord fibrosis, commissural fusion and retraction of the anterior mitral valve leaflet. In the operation we resected the mitral supravalvular membrane, performed a commisurotomy and a bovine pericar-dial patch ampliation of the anterior mitral valve leaflet. Although transesophageal echocardiography reported a moderate residual mitral valve regurgitation, weaning of cardiopulmonary by-pass at the first time was successful without early hemodynamic deterioration. In the early postoperative period he developed clinical and radiologic signs of acute pulmonary edema, and six hours later was reoperated for mitral valve replacement with an aortic St. Jude 17 mechanical prosthesis placed invertedly in a supra annular mitral position, with a successful postoperative course. The second patient was a eight months female infant who had a dysplastic mitral valve with a single shortened and forked papillary muscle. We performed a bilateral commisurotomy, papillary muscle fenestration and an annuloplasty with a bovine pericardial hemiannulus. Additionally she had a ventricular septal defect that was repaired with a bovine pericardial patch and a patent ductus arteriosus that was closed at the same time. Moderate stenosis and regurgitation without residual septal defects was reported by the transesophageal intraoperative echocardiography. Postoperatively she had prolonged mechanic ventilation due to heart failure, and nine days later we decided to reoperate this patient for mitral valve replacement with a mechanical Carbomedics 17 mitral valve in annular position, with good postoperative results. Up to date, both patients are asymptomatic and with appropriate prosthetic valve performance at the echocardiographic control. </p><p class="elsevierStylePara">Clinical follow-up was made at a mean time of 29 months (range, 15 days to 57 months) in all of the survivors. <span class="elsevierStyleBold">Figure 3</span> shows functional class stratification according to the NYHA and the modified Ross classification evolution between preoperative and mid-term follow-up in patients with mitral insufficiency. All of the patients with mitral stenosis which had III NYHA/Ross functional class improved to class I. Morbidity rate at mid time follow-up was of 15.3% (two patients). One of these patients developed an embolic stroke with left hemiplegia and gastroesophageal reflux. The other one required a mitral prosthetic valve replacement two years after the first operation, because of mitral valve repair failure. Additionally, a patient in our series developed mitral valve repair failure at the mid time (22 months), of no important clinical significance. In this case, optimum medical treatment has allowed us to delay the time of reoperation until he reaches the adequate age to perform a definitive prosthetic valve replacement. </p><p class="elsevierStylePara"><img src="293v80n02-13153400fig7.jpg" alt="Figure 3. Change in NYHA/Ross functional class after mitral valve repair in patients with mitral insufficiency."></img></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Figure 3. </span>Change in NYHA/Ross functional class after mitral valve repair in patients with mitral insufficiency.</p><p class="elsevierStylePara">We did an echocardiographic follow-up in eight of the 13 survivors (65%) at a mean time of 1.8 years (range, one month to 2.6 years). All the remaining patients who did not have echocardiographic follow-up were asymptomatic. Only three of the patients who had echocardiographic follow-up were symptomatic. Therefore, we made an echo-cardiografic follow-up in all the symptomatic patients and in 50% of the asymptomatic ones at a mean time of 21 months (range, 10 to 33 months). In <span class="elsevierStyleBold">Figure 4</span> we resume the clinical outcome of our patients. There were no late deaths. <span class="elsevierStyleBold">Figure 5</span> shows that the overall survival rate after surgical mitral valve repair is of 93% at 30 days and does not vary up to 3.5 year follow-up. It also shows freedom from reoperation for mitral valve prosthetic replacement survival curve in the early and mid time follow-up. We can say that the successful rate observed in our series for surgical mitral valve repair was 84% at 30 days and 77% at 3.5 years. The estimated freedom from reoperation for mitral valve prosthetic replacement survival curve al 5 years was 77% and 66% at 10 years follow-up. </p><p class="elsevierStylePara"><img src="293v80n02-13153400fig8.jpg" alt="Figure 4. Clinical follow-up outcome of surgical treatment in congenital mitral valve malformations. MVR= Mitral valve repair, MVPR= Mitral valve prosthetic replacement, MVP= Mitral valve prosthesis, pt(s)= patient(s)."></img></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Figure 4. </span>Clinical follow-up outcome of surgical treatment in congenital mitral valve malformations. MVR= Mitral valve repair, MVPR= Mitral valve prosthetic replacement, MVP= Mitral valve prosthesis, pt(s)= patient(s).</p><p class="elsevierStylePara"><img src="293v80n02-13153400fig9.jpg" alt="Figure 5. Early and mid-term curves and tendencies of overall survival and freedom from reoperation for mitral valve prosthetic replacement survival after surgical mitral valve repair."></img></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Figure 5.</span> Early and mid-term curves and tendencies of overall survival and freedom from reoperation for mitral valve prosthetic replacement survival after surgical mitral valve repair.</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Discussion</span></p><p class="elsevierStylePara">The spectrum of congenital mitral valve malformations ranges from the readily reparable anterior mitral leaflet cleft to the restrictive and challenging lesions of mitral stenosis. Whatever the abnormality, the incidence of associated heart defects is high<span class="elsevierStyleSup">6,9,11</span> and can have a significant impact on the eventual clinical outcome. </p><p class="elsevierStylePara">Because of the significant short- and long-term problems with mechanical and bioprosthetic mitral valves in children<span class="elsevierStyleSup">21,22</span>, considerable attention has been paid to mitral remodeling techniques<span class="elsevierStyleSup">9,11,15</span> for both incompetent and stenotic valves. This trend has lowered the perioperative mortality from as high as 21% to 43% for mitral valve replacement<span class="elsevierStyleSup">5,23,24</span> to as low as 0% to 5% for mitral valve repair.<span class="elsevierStyleSup">9,10,15,16,23</span> Our overall operative mortality is along with these trends. </p><p class="elsevierStylePara">One of the most common causes of mitral insufficiency in our series was anterior leaflet valve cleft, as well as shortening of tendineal chords. The simple cleft closure with or without papillary muscles fenestration was the only procedure used for a correct mitral valve competence. More challenging is the infant and young child with annular dilatation and mitral insufficiency who will require native annular remodeling with a posterior hemiannulus. Although we used a rigid Carpentier hemiannulus in a young child, in infants and children in growing ages there are more problems in choosing a correct prosthesis size. Chavaud and associates<span class="elsevierStyleSup">9</span> have approached this problem by performing the posterior annular reduction without the use of a rigid prosthesis. Based on Rowlatt's,<span class="elsevierStyleSup">25</span> measurements they used Goretex or pericardial hemiannulus for the reduction of the posterior native mitral annulus, because the anterior aspect does not enlarge as much due to its fibrous constitution. In our series we only used one Carpentier rigid hemiannulus in a young child. All of the other children received a bovine pericardial hemiannulus. This biologic tissue is similar to the autologus pericardium, but has the advantage in that it is easier to manipulate. The manufacturing of this material in our institution and its availability in different sizes and thickness without an additional economic cost, makes bovine pericardium the material of choice to perform the mitral hemiannular posterior reduction in infants and children at growing ages in our series. </p><p class="elsevierStylePara">The most common cause of mitral stenosis in our series was the parachute-like mitral valve, which was treated with fenestration of papillary muscles in most of the cases. Another cause was supravalvular mitral membrane, usually associated with other stenotic lesions such as redundant valvular tissue, and commisure and/or papillary muscle fusion. For this reason, simple resection of the supravalvular membrane was not able to achieve an appropriate relief of the mitral stenosis, so we associated another procedure such as open mitral commisurotomy, papillary muscle fenestration, or resection of redundant valvular tissue.</p><p class="elsevierStylePara">There were three patients in our series who needed reoperation because of failure of the original mitral valve surgical repair. Transesophageal intraoperatory echo-cardiography was very useful to evaluate the immediate results of surgical mitral valve repair, and identify early technical failure. We only had a patient who developed hemodynamic instability and needed mitral valve pros-thesis replacement before chest closure. Hemodynamic status was acceptable in the other two cases after weaning of cardiopulmonary bypass. This fact allowed the surgeon for chest closure, but they developed cardiac failure in the Intensive Care Unit that requiring reoperation for mitral valve prosthetic replacement. One of them was reoperated before 30 days and the other after two years of the first mitral valve repair. The early reoperation rate compares favorably to other reports <span class="elsevierStyleSup">5,6,13,15</span> of mitral valve repair in children. The immediate reoperation rate before chest closure on the basis of hemodynamic findings and intraoperative transesophageal echocardiography is not widely reported. In our series the outcome of the 3 reoperated patients (23%) was favorable after the mitral valve prosthetic replacement. Most reports dealing with congenital anomalies<span class="elsevierStyleSup">5,9,10</span> recognize the importance of intraoperative transesophageal echocardiography for functional evaluation giving the surgeon the option for reintervention as deemed necessary.</p><p class="elsevierStylePara">Although we believe that intraoperative transesophageal echocardiography is an important method that allows the surgeon to decide which is the best surgical mitral repair technique to use and to evaluate the early results, our final decision depends on the type of patient we deal with. The low socioeconomic level of the majority of our patients and their rural environment difficults an appropiate oral anticoagulation treatment, because of the lack of INR laboratory resources close to home. This is the reason why we try to preserve their native mitral valve the longer time as possible, even if we know by echocardio-graphic evaluation that the result is not always entirely satisfactory.</p><p class="elsevierStylePara">Our overall survival early and mid-term rate, as well as the freedom from reoperation for mitral valve prosthetic replacement survival rate were favorable and similar to the experience of other centers.<span class="elsevierStyleSup">5,9,10,15,26 </span>The low incidence of thromboembolic episodes observed in our patients is also consistent with the findings of others<span class="elsevierStyleSup">5,9,10,15,26</span> and contributes to the low postoperative morbidity. We believe that anticoagulation therapy is not needed for patients with surgical mitral valve repair except for the first three months postoperatively in our only case where Carpentier´s rigid hemiannulus prosthesis was used. This is the time a rigid hemiannulus prosthesis requires to become endothelized. </p><p class="elsevierStylePara"><span class="elsevierStyleBold">Conclusion</span></p><p class="elsevierStylePara">Malformations of the mitral valve are not a common pathology, and our experience with this study has the proper limitations of a retrospective one. Although this series cannot lead us to drive definite conclusions, we can say that mitral valve repair in pediatric patients is probably the best technique option in the treatment of congenital malformations of the mitral valve, because of the satisfactory early and mid-term outcomes, low global mortality and a high freedom from reoperation for mitral valve prosthetic replacement survival rate. In addition, mitral valve repair allows preservation of the native valve without interfering with its growth, avoiding anticoagulation at an early age. On the other hand, the routine use of transesophageal intraoperative echocardiography must be highly recommended for evaluation of results in a surgical mitral valve repair procedure. </p><hr></hr><p class="elsevierStylePara"><span class="elsevierStyleItalic">Corresponding author:</span> Pedro José Curi Curi.<br></br> Juan Badiano Nº 1, Colonia Sección XVI, Tlalpan. Mexico City.<br></br> Telephone: 55545828. Fax: 52 (55) 55730994.<br></br><span class="elsevierStyleItalic">E-mail:</span><a href="mailto:pcuricuri@gmail.com" class="elsevierStyleCrossRefs">pcuricuri@gmail.com</a></p><p class="elsevierStylePara">Received in July 9, 2009;<br></br> accepted in October 9, 2009.</p>" "pdfFichero" => "293v80n02a13153400pdf001.pdf" "tienePdf" => true "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec192619" "palabras" => array:1 [ 0 => "Reparación valvular mitral; Cirugía cardiaca pediátrica; México" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec192618" "palabras" => array:1 [ 0 => "Mitral valve repair; Cardiac pediatric surgery; Mexico" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:1 [ "resumen" => "Surgical development of mitral valve repair techniques in pediatric patients has been slow because of the great variety in the presentation of congenital mitral valve malformations and the still unknown growing effect over the complex mitral valve apparatus. The aim of this study is to review our early an mid-term institutional outcomes in surgical repair of congenital mitral valve malformations. We studied retrospectively 14 patients with surgical repair of congenital mitral valve malformations in a 5 year period. Clinical and echocardiographic follow-up at a mean of 25 months was performed in all cases. Operative morbidity was 77% and operative mortality 7%. There were no late deaths. Clinical functional class stratification at the mid-term improved in 73% of survivors and did not change in the remaining 27%. Freedom from reoperation for mitral valve prosthetic replacement due to mitral valve repair failure was 84% at 30 days and 77% at 3.5 years. Surgical repair is probably the best technique option in the treatment of congenital malformations of the mitral valve, and transesophageal intraoperatory echocardiography must be highly recommended for evaluation of results." ] "es" => array:1 [ "resumen" => "El desarrollo de las técnicas de plastía mitral en el paciente pediátrico ha sido lento debido a la gran variabilidad de presentación de las lesiones mitrales congénitas, y al poco conocido efecto del crecimiento sobre el complejo aparato valvular mitral. El objetivo de este estudio fue revisar nuestra experiencia institucional en el corto y mediano plazo en la reparación quirúrgica de las valvulopatías mitrales congénitas. En forma retrospectiva se estudió una serie de 14 pacientes operados de reparación quirúrgica por valvulopatía mitral congénita en un lapso de cinco años. Se realizó seguimiento clínico y ecográfico en todos los casos a los 25 meses en promedio. La morbilidad operatoria de la serie fue de 77% y la mortalidad operatoria de 7%. No hubo mortalidad tardía. En el mediano plazo, la capacidad funcional mejoró en 73% de los sobrevivientes y se mantuvo en 27%. El índice de sobrevida libre de re-operación para cambio valvular por falla de la plastía mitral fue de 84% a los 30 días y de 77% a los 3.5 años. La reparación valvular mitral en el paciente pediátrico es probablemente la técnica de elección en el tratamiento quirúrgico de la patología valvular mitral congénita, y la ecocardiografía transesofágica intraoperatoria debe ser considerada como una herramienta altamente recomendable para evaluar los resultados." ] ] "multimedia" => array:9 [ 0 => array:8 [ "identificador" => "fig1" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "293v80n02-13153400fig1.jpg" "Alto" => 1100 "Ancho" => 1020 "Tamanyo" => 171164 ] ] "descripcion" => array:1 [ "en" => "Schematic diagrams of surgical mitral valve repair techniques and number of cases." ] ] 1 => array:8 [ "identificador" => "tbl1" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tablaImagen" => array:1 [ 0 => array:4 [ "imagenFichero" => "293v80n02-13153400fig2.jpg" "imagenAlto" => 1254 "imagenAncho" => 2091 "imagenTamanyo" => 436488 ] ] ] ] ] "descripcion" => array:1 [ "en" => "Clinical features of the studied cases. CML= Complex mitral lesion, >= Predominance of, St.= stenosis, Insuf.= insufficiency." ] ] 2 => array:8 [ "identificador" => "tbl2" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tablaImagen" => array:1 [ 0 => array:4 [ "imagenFichero" => "293v80n02-13153400fig3.jpg" "imagenAlto" => 408 "imagenAncho" => 1029 "imagenTamanyo" => 55297 ] ] ] ] ] "descripcion" => array:1 [ "en" => "Associated congenital malformations." ] ] 3 => array:8 [ "identificador" => "tbl3" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tablaImagen" => array:1 [ 0 => array:4 [ "imagenFichero" => "293v80n02-13153400fig4.jpg" "imagenAlto" => 670 "imagenAncho" => 1041 "imagenTamanyo" => 109570 ] ] ] ] ] "descripcion" => array:1 [ "en" => "Patient groups according to Carpentier's pathophysiological classification." ] ] 4 => array:8 [ "identificador" => "tbl4" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tablaImagen" => array:1 [ 0 => array:4 [ "imagenFichero" => "293v80n02-13153400fig5.jpg" "imagenAlto" => 987 "imagenAncho" => 1033 "imagenTamanyo" => 159516 ] ] ] ] ] "descripcion" => array:1 [ "en" => "Operative morbidity causes." ] ] 5 => array:8 [ "identificador" => "fig2" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "293v80n02-13153400fig6.jpg" "Alto" => 837 "Ancho" => 1558 "Tamanyo" => 83815 ] ] "descripcion" => array:1 [ "en" => "Number and percentage of associated surgical procedures." ] ] 6 => array:7 [ "identificador" => "fig3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "293v80n02-13153400fig7.jpg" "Alto" => 762 "Ancho" => 1008 "Tamanyo" => 64588 ] ] "descripcion" => array:1 [ "en" => "3153400fig7.jpg" width="1008" height="762" alt="Figure 3. Change in NYHA/Ross functional class after mitral val" ] ] 7 => array:8 [ "identificador" => "fig4" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "293v80n02-13153400fig8.jpg" "Alto" => 1200 "Ancho" => 1891 "Tamanyo" => 183773 ] ] "descripcion" => array:1 [ "en" => "Clinical follow-up outcome of surgical treatment in congenital mitral valve malformations. MVR= Mitral valve repair, MVPR= Mitral valve prosthetic replacement, MVP= Mitral valve prosthesis, pt(s)= patient(s)." ] ] 8 => array:8 [ "identificador" => "fig5" "etiqueta" => "Figure 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "293v80n02-13153400fig9.jpg" "Alto" => 733 "Ancho" => 995 "Tamanyo" => 76463 ] ] "descripcion" => array:1 [ "en" => "Early and mid-term curves and tendencies of overall survival and freedom from reoperation for mitral valve prosthetic replacement survival after surgical mitral valve repair." ] ] ] "bibliografia" => array:2 [ "titulo" => "Bibliography" "seccion" => array:1 [ 0 => array:1 [ "bibliografiaReferencia" => array:26 [ 0 => array:3 [ "identificador" => "bib1" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "The mitral apparatus." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "Perloff JK" 1 => "Roberts WC." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "fecha" => "Circulation 1972" "volumen" => "46" "paginaInicial" => "227" "paginaFinal" => "239" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib2" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Pathology of the mitral valve: Introduction to plastic and reconstructive valve surgery." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "Carpentier A" 1 => "Guerinon J" 2 => "Deloche A" 3 => "et al." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:1 [ "tituloSerie" => "En: Kalmanson D (ed): The mitral valve, A Pluridisciplinary Approach" ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib3" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Valve repair improves the outcome of surgery for mitral regurgitation." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "Enriquez-Sarano M" 1 => "Schaff HV" 2 => "Orszulak TA" 3 => "et al." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "A multivariate analysis" "fecha" => "Circulation 1995" "volumen" => "91" "paginaInicial" => "1022" "paginaFinal" => "1028" ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib4" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Valve repair with Carpen-tier techniques." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "Deloche A" 1 => "Jebara VA" 2 => "Relland JY" 3 => "et al." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "The second decade" "fecha" => "J Thorac Cardiovasc Surg 1990" "volumen" => "99" "paginaInicial" => "990" "paginaFinal" => "1002" ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib5" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Early and late results of mitral valve repair in children." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "Aharon AS" 1 => "Laks H" 2 => "Drinkwater DC" 3 => "et al." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "fecha" => "J Thorac Cardiovasc Surg 1994" "volumen" => "107" "paginaInicial" => "1262" "paginaFinal" => "1271" ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib6" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Surgery for congenital abnormalities of the mitral valve at the Hospital for Sick Children, London from 1969 -1983." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "Almeida RS" 1 => "Elliott MJ" 2 => "Robinson PJ" 3 => "et al." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "fecha" => "J Cardiovasc Surg 1988" "volumen" => "29" "paginaInicial" => "95" "paginaFinal" => "99" ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib7" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Surgical treatment of congenital lesions of the mitral valve." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "Anderson RH." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "fecha" => "Cardiol Young 1997" "volumen" => "7" "paginaInicial" => "2" "paginaFinal" => "4" ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib8" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Classification of congenital malformations of the mitral valve and their surgical management. In: Crupi G, Parenzan L, Anderson RG, eds. Perspectives, En: pediatric cardiology, vol. 2." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "Carpentier A" 1 => "Chauvaud S" 2 => "Mihaileanu S." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Part 3, Pediatric cardiac surgery" "fecha" => "Mt Kisco, NY" "volumen" => "Futura Publishing Company, 1990" "paginaInicial" => "97" "paginaFinal" => "102" ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib9" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Surgical treatment of congenital mitral valve insufficiency :"The Hospital Broussais" experience." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "Chauvaud SM" 1 => "Milhaleanu SA" 2 => "Gaer JA.R" 3 => "et al." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "fecha" => "Cardiol Young 1997" "volumen" => "7" "paginaInicial" => "5" "paginaFinal" => "14" ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib10" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Surgical treatment of congenital mitral valve stenosis: "The Hospital Broussais" experience." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "Chauvau SM" 1 => "Milhaleanu SA" 2 => "Gaer JA.R" 3 => "et al." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "fecha" => "Cardiol Young 1997" "volumen" => "7" "paginaInicial" => "15" "paginaFinal" => "21" ] ] ] ] ] ] 10 => array:3 [ "identificador" => "bib11" "etiqueta" => "11" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Surgical experience with reparative techniques in patients with congenital mitral valvular anomalies." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "Coles JG" 1 => "Williams WG" 2 => "Watanabe T" 3 => "et al." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "fecha" => "Circulation 1987" "volumen" => "76" "paginaInicial" => "117" "paginaFinal" => "122" ] ] ] ] ] ] 11 => array:3 [ "identificador" => "bib12" "etiqueta" => "12" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Mitral valve replacement in the first year of life." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "Kadoba K" 1 => "Jonas RA" 2 => "Mayer JE" 3 => "et al." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "fecha" => "J Thorac Cardiovasc Surg 1990" "volumen" => "100" "paginaInicial" => "762" "paginaFinal" => "768" ] ] ] ] ] ] 12 => array:3 [ "identificador" => "bib13" "etiqueta" => "13" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Early and late results of reconstructive operation for congenital mitral regurgitation in pediatric age group." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "Okita Y" 1 => "Miki S" 2 => "Kusuhar.a" 3 => "et al." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "fecha" => "J Thorac Cardiovasc Surg 1988" "volumen" => "96" "paginaInicial" => "294" "paginaFinal" => "298" ] ] ] ] ] ] 13 => array:3 [ "identificador" => "bib14" "etiqueta" => "14" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Anatomic types of congenital mitral stenosis: report of 49 autopsy cases with consideration of diagnosis and surgical implications." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "Ruckman RN" 1 => "Van Praagh R." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "fecha" => "Am J Cardiol 1978" "volumen" => "42" "paginaInicial" => "592" "paginaFinal" => "601" "itemHostRev" => array:3 [ "pii" => "S0169500210001613" "estado" => "S300" "issn" => "01695002" ] ] ] ] ] ] ] 14 => array:3 [ "identificador" => "bib15" "etiqueta" => "15" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Surgery for congenital mitral valve disease in the first year of life." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "Sousa UM" 1 => "Galletti L" 2 => "Gayet FL" 3 => "et al." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "fecha" => "J Thorac Cardiovasc Surg 1995" "volumen" => "109" "paginaInicial" => "164" "paginaFinal" => "176" ] ] ] ] ] ] 15 => array:3 [ "identificador" => "bib16" "etiqueta" => "16" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Repair of congenitally malformed mitral valve in children." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "Stellin G" 1 => "Bortolotti U" 2 => "Mazzucco A" 3 => "et al." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "fecha" => "J Thorac Cardiovasc Surg 1988" "volumen" => "95" "paginaInicial" => "480" "paginaFinal" => "485" ] ] ] ] ] ] 16 => array:3 [ "identificador" => "bib17" "etiqueta" => "17" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Estenosis mitral congénita." "idioma" => "es" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "Alva C" 1 => "González B" 2 => "Meléndez C" 3 => "et al." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Experiencia1991-2001" "fecha" => "Arch Cardiol Mex 2001" "volumen" => "71" "paginaInicial" => "206" "paginaFinal" => "213" ] ] ] ] ] ] 17 => array:3 [ "identificador" => "bib18" "etiqueta" => "18" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Circulation 1994." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "AHA Medical / Scientific Statement: 1994 revisions to classification of functional capacity and objective assessment of patients with diseases of the heart." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:3 [ "volumen" => "90" "paginaInicial" => "644" "paginaFinal" => "645" ] ] ] ] ] ] 18 => array:3 [ "identificador" => "bib19" "etiqueta" => "19" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "al." "idioma" => "ro" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "Ross RD" 1 => "Daniels SR" 2 => "Schwartz DC" 3 => "et." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Plasma norepinephrine levels in infants and children with congestive heart failure" "fecha" => "Am J Cardiol 1987" "volumen" => "59" "paginaInicial" => "911" "paginaFinal" => "914" ] ] ] ] ] ] 19 => array:3 [ "identificador" => "bib20" "etiqueta" => "20" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Intraoperative transesophageal doppler color flow imaging used to guide patient selection and operative treatment of ischemic mitral regurgitation." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "Sheikh KH" 1 => "Bengtson JR" 2 => "Rankin JS" 3 => "et al." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "fecha" => "Circulation 1991" "volumen" => "84" "paginaInicial" => "594" "paginaFinal" => "604" ] ] ] ] ] ] 20 => array:3 [ "identificador" => "bib21" "etiqueta" => "21" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Five- year follow up after valve replacement with the St." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "Borkon AM" 1 => "Soule L" 2 => "Reitz BA" 3 => "et al." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Jude Medical valve in infants and children" "fecha" => "Circulation 1986" "volumen" => "74" "paginaInicial" => "110" "paginaFinal" => "15" ] ] ] ] ] ] 21 => array:3 [ "identificador" => "bib22" "etiqueta" => "22" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Late failure of porcine valve heterografts in children." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "Geha AS" 1 => "Laks H" 2 => "Stansel HC Jr" 3 => "et al." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "fecha" => "J Thorac Cardiovasc Surg 1979" "volumen" => "78" "paginaInicial" => "351" "paginaFinal" => "364" ] ] ] ] ] ] 22 => array:3 [ "identificador" => "bib23" "etiqueta" => "23" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Mitral valve replacement in the first year of life." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "Kadoba K" 1 => "Jonas RA" 2 => "Mayer JE" 3 => "et al." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "fecha" => "J Thorac Cardiovasc Surg 1990" "volumen" => "100" "paginaInicial" => "762" "paginaFinal" => "768" ] ] ] ] ] ] 23 => array:3 [ "identificador" => "bib24" "etiqueta" => "24" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Fowler RS." "idioma" => "de" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "Williams WG" 1 => "Pollock JC" 2 => "Geiss DM" 3 => "et al." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Experience with aortic and mitral valve replacement in children" "fecha" => "J Thorac Cardiovasc Surg 1981" "volumen" => "81" "paginaInicial" => "326" "paginaFinal" => "333" "itemHostRev" => array:3 [ "pii" => "S0169500206005356" "estado" => "S300" "issn" => "01695002" ] ] ] ] ] ] ] 24 => array:3 [ "identificador" => "bib25" "etiqueta" => "25" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "The quantitative anatomy of the child''s heart." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "Rowlatt UF" 1 => "Rimoldi HJ.A" 2 => "Lev M." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "fecha" => "Pediatr Clin North Am 1963" "volumen" => "10" "paginaInicial" => "499" "paginaFinal" => "588" ] ] ] ] ] ] 25 => array:3 [ "identificador" => "bib26" "etiqueta" => "26" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Surgical repair of the con-Surgical repair of the congenitally malformed mitral valve in infants and children." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "Zias E" 1 => "Mavroudis C" 2 => "Backer C" 3 => "et al." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "fecha" => "Ann Thorac Surg 1998" "volumen" => "66" "paginaInicial" => "1551" "paginaFinal" => "1559" ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/14059940/0000008000000002/v0_201307091127/X1405994010534009/v0_201307091128/en/main.assets" "Apartado" => array:4 [ "identificador" => "14592" "tipo" => "SECCION" "es" => array:2 [ "titulo" => "Investigación clínica" "idiomaDefecto" => true ] "idiomaDefecto" => "es" ] "PDF" => "https://static.elsevier.es/multimedia/14059940/0000008000000002/v0_201307091127/X1405994010534009/v0_201307091128/en/293v80n02a13153400pdf001.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X1405994010534009?idApp=UINPBA00004N" ]
Article information
ISSN: 14059940Original language: English
The statistics are updated each day
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 17 | 0 | 17 |
| 2024 October | 70 | 3 | 73 |
| 2024 September | 99 | 5 | 104 |
| 2024 August | 58 | 5 | 63 |
| 2024 July | 70 | 3 | 73 |
| 2024 June | 104 | 9 | 113 |
| 2024 May | 126 | 3 | 129 |
| 2024 April | 86 | 7 | 93 |
| 2024 March | 158 | 11 | 169 |
| 2024 February | 169 | 4 | 173 |
| 2024 January | 179 | 16 | 195 |
| 2023 December | 180 | 17 | 197 |
| 2023 November | 325 | 11 | 336 |
| 2023 October | 378 | 24 | 402 |
| 2023 September | 185 | 2 | 187 |
| 2023 August | 130 | 10 | 140 |
| 2023 July | 197 | 17 | 214 |
| 2023 June | 166 | 7 | 173 |
| 2023 May | 239 | 21 | 260 |
| 2023 April | 148 | 4 | 152 |
| 2023 March | 180 | 17 | 197 |
| 2023 February | 126 | 12 | 138 |
| 2023 January | 146 | 11 | 157 |
| 2022 December | 100 | 13 | 113 |
| 2022 November | 104 | 14 | 118 |
| 2022 October | 107 | 11 | 118 |
| 2022 September | 123 | 16 | 139 |
| 2022 August | 104 | 20 | 124 |
| 2022 July | 92 | 19 | 111 |
| 2022 June | 122 | 21 | 143 |
| 2022 May | 93 | 19 | 112 |
| 2022 April | 88 | 8 | 96 |
| 2022 March | 109 | 10 | 119 |
| 2022 February | 90 | 11 | 101 |
| 2022 January | 196 | 23 | 219 |
| 2021 December | 103 | 10 | 113 |
| 2021 November | 83 | 17 | 100 |
| 2021 October | 118 | 22 | 140 |
| 2021 September | 87 | 18 | 105 |
| 2021 August | 95 | 11 | 106 |
| 2021 July | 64 | 8 | 72 |
| 2021 June | 53 | 10 | 63 |
| 2021 May | 96 | 10 | 106 |
| 2021 April | 215 | 29 | 244 |
| 2021 March | 160 | 7 | 167 |
| 2021 February | 74 | 13 | 87 |
| 2021 January | 108 | 18 | 126 |
| 2020 December | 102 | 18 | 120 |
| 2020 November | 135 | 13 | 148 |
| 2020 October | 77 | 11 | 88 |
| 2020 September | 97 | 11 | 108 |
| 2020 August | 62 | 7 | 69 |
| 2020 July | 62 | 18 | 80 |
| 2020 June | 54 | 12 | 66 |
| 2020 May | 65 | 10 | 75 |
| 2020 April | 63 | 13 | 76 |
| 2020 March | 97 | 11 | 108 |
| 2020 February | 120 | 4 | 124 |
| 2020 January | 121 | 12 | 133 |
| 2019 December | 98 | 14 | 112 |
| 2019 November | 44 | 3 | 47 |
| 2019 October | 69 | 8 | 77 |
| 2019 September | 99 | 10 | 109 |
| 2019 August | 61 | 7 | 68 |
| 2019 July | 123 | 8 | 131 |
| 2019 June | 213 | 24 | 237 |
| 2019 May | 284 | 35 | 319 |
| 2019 April | 188 | 22 | 210 |
| 2019 March | 34 | 4 | 38 |
| 2019 February | 47 | 7 | 54 |
| 2019 January | 35 | 9 | 44 |
| 2018 December | 41 | 6 | 47 |
| 2018 November | 57 | 5 | 62 |
| 2018 October | 173 | 9 | 182 |
| 2018 September | 139 | 11 | 150 |
| 2018 August | 62 | 5 | 67 |
| 2018 July | 57 | 1 | 58 |
| 2018 June | 58 | 6 | 64 |
| 2018 May | 71 | 6 | 77 |
| 2018 April | 49 | 1 | 50 |
| 2018 March | 54 | 1 | 55 |
| 2018 February | 69 | 1 | 70 |
| 2018 January | 58 | 0 | 58 |
| 2017 December | 55 | 0 | 55 |
| 2017 November | 40 | 1 | 41 |
| 2017 October | 51 | 7 | 58 |
| 2017 September | 45 | 7 | 52 |
| 2017 August | 38 | 2 | 40 |
| 2017 July | 34 | 3 | 37 |
| 2017 June | 60 | 2 | 62 |
| 2017 May | 75 | 3 | 78 |
| 2017 April | 39 | 0 | 39 |
| 2017 March | 78 | 17 | 95 |
| 2017 February | 103 | 14 | 117 |
| 2017 January | 40 | 1 | 41 |
| 2016 December | 35 | 3 | 38 |
| 2016 November | 37 | 4 | 41 |
| 2016 October | 26 | 3 | 29 |
| 2016 September | 21 | 1 | 22 |
| 2016 August | 12 | 3 | 15 |
| 2016 July | 31 | 6 | 37 |
| 2016 June | 82 | 13 | 95 |
| 2016 May | 96 | 19 | 115 |
| 2016 April | 83 | 11 | 94 |
| 2016 March | 86 | 22 | 108 |
| 2016 February | 74 | 16 | 90 |
| 2016 January | 73 | 7 | 80 |
| 2015 December | 85 | 18 | 103 |
| 2015 November | 85 | 6 | 91 |
| 2015 October | 81 | 6 | 87 |
| 2015 September | 63 | 8 | 71 |
| 2015 August | 102 | 10 | 112 |
| 2015 July | 227 | 9 | 236 |
| 2015 June | 85 | 1 | 86 |
| 2015 May | 96 | 5 | 101 |
| 2015 April | 90 | 7 | 97 |
| 2015 March | 133 | 13 | 146 |
| 2015 February | 130 | 7 | 137 |
| 2015 January | 69 | 5 | 74 |
| 2014 December | 89 | 4 | 93 |
| 2014 November | 88 | 3 | 91 |
| 2014 October | 87 | 5 | 92 |
| 2014 September | 91 | 5 | 96 |
| 2014 August | 77 | 2 | 79 |
| 2014 July | 66 | 1 | 67 |
| 2014 June | 79 | 2 | 81 |
| 2014 May | 67 | 1 | 68 |
| 2014 April | 67 | 2 | 69 |
| 2014 March | 128 | 9 | 137 |
| 2014 February | 102 | 9 | 111 |
| 2014 January | 102 | 4 | 106 |
| 2013 December | 90 | 7 | 97 |
| 2013 November | 98 | 14 | 112 |
| 2013 October | 138 | 8 | 146 |
| 2013 September | 89 | 7 | 96 |
| 2013 August | 109 | 11 | 120 |
| 2013 July | 97 | 8 | 105 |
| 2013 June | 57 | 9 | 66 |
| 2013 May | 72 | 6 | 78 |
| 2013 April | 57 | 15 | 72 |
| 2013 March | 39 | 10 | 49 |
| 2013 February | 30 | 5 | 35 |
| 2013 January | 49 | 2 | 51 |
| 2012 December | 8 | 2 | 10 |
| 2012 November | 6 | 3 | 9 |
| 2012 October | 4 | 2 | 6 |
| 2012 September | 0 | 1 | 1 |
| 2010 March | 600 | 0 | 600 |
Show all