Çocuklarda mekanik aort kapak replasmani

Year 2023, , 459 - 463, 30.09.2023

Başak Soran Türkcan , Mustafa Yılmaz , Yasemin Özdemir Şahan , Ata Niyazi Ecevit , Atakan Atalay , Cemal Levent Bırıncıoğlu

https://doi.org/10.18663/tjcl.1336997

Abstract

Amaç: Aort darlığı, kalbin sol ventrikülünden aorta kan akışını düzenleyen kapak olan aort kapağının daralması ile karakterize doğuştan bir kalp hastalığıdır. Aort darlığı çocuklar da dahil olmak üzere her yaştan bireyi etkileyebilirken, pediatrik hastalarda benzersiz zorluklar ortaya çıkarır. Çocuklarda aort darlığının şiddeti, hafif ile şiddetli arasında geniş ölçüde değişebilir ve göğüs ağrısı, yorgunluk ve nefes darlığı gibi semptomlarla kendini gösterebilir. Aort darlığı tedavi edilmezse önemli komplikasyonlara yol açabilir ve çocuğun genel sağlığını ve yaşam kalitesini olumsuz etkileyebilir.
Gereç ve Yöntemler: Şubat 2019-Haziran 2023 tarihleri arasında hastanemizde aort kapak patolojileri nedeniyle 38 hasta ameliyat edildi. 11 hastaya aort kapak tamiri, 27 hastaya aort kapak replasmanı yapıldı. Hastaların yaşı, cinsiyeti, vücut ağırlığı, aort kapağı patolojisi, aort kapağı patolojisinin etiyolojisi (konjenital, romatizmal, enfektif endokardit), Marfan Sendromu varlığı, geçirilmiş ameliyat öyküsü, aort anulus çapı, kullanılan kapak tipi, kapak boyutu, yapıldıysa aortik kök genişletme prosedürü, kardiyopulmoner baypas süresi, kros klemp süresi, yoğun bakımda kalış süresi, serviste kalış süresi, inotrop gereksinimi, inotrop kullanım süresi, mekanik ventilasyon süresi, drenaj miktarı, revizyon gereksinimi ve mortalite retrospektif olarak hasta dosyalarından ve hastane veri tabanından tarandı.
Bulgular: Hastaların medyan yaşı 12,96±3,38 (IQR=11,00-16,00) yıl olup, ağırlıkları 43,81±14,21 kg arasında değişmekteydi. Sekiz hasta (%29.6) kadın, 19 hasta erkekti(%70.4). 8 hastada (%29.6) aort darlığı, 9 hastada (%33.3) aort yetmezliği ve 10 hastada (%37) hem aort darlığı hem de yetmezlik tanısı kondu. Hastaların aort anulus çapları 21,59±4,64 milimetre idi. 11 hastada (%40.7) dar aort anulus nedeniyle anterior veya posterior kök genişletmesi yapıldı. 7 hastaya Nick (%63.6), 2 hastaya Manoughian (%18.2) ve 2 hastaya Konno (%18.2) prosedürü uygulandı. Hastalarda kullanılan mekanik aort kapak ölçülerine bakıldığında 5 hastada 19 numara protez aort kapağı (%18.5), 8 hastada 21 numara protez aort kapağı (%29.6), 8 hastada 23 numara protez aort kapağı (%29.6), 6 hastada ise 25 numara protez aort kapağı (%22.2) kullanıldı. Mortalite 3 hastada (%11.1) görüldü Mortalite nedenleri düşük kardiyak output, nörolojik olaylar ve sepsis olarak sıralanabilir.
Tartışma: Nihai hedef, aort kapağı replasmanı yapılan çocukların sağlıklı ve tatmin edici bir yaşam sürdürebilmelerini sağlamaktır. Yaklaşımlarımızı sürekli iyileştirerek ve her vakadan öğrenerek, çocuklarda aort kapağı sorunlarının tedavisinde önemli adımlar atabilir ve onlara mümkün olan en iyi sonuçları sunabiliriz.
Sonuç: Çocuklarda aort kapak replasmanı, sadece cerrahi prosedürün kendisine değil, aynı zamanda uzun vadeli yönetim ve desteğe odaklanan multidisipliner bir yaklaşım gerektirir. Devam eden ilerlemeler ve işbirlikçi bir zihniyetle, bu genç hastalara sağlanan bakımı iyileştirmeye ve gelişmelerine yardımcı olmaya devam edebiliriz.

Keywords

Aortik kapak replasmanı, Aort darlığı, Aort yetmezliği, Aortik kök genişletme

Mechanical aortic valve replacement in children

Abstract

Aim: Aortic stenosis is a congenital heart disease characterized by the narrowing of the aortic valve, the valve that regulates blood flow from the heart's left ventricle to the aorta. While aortic stenosis can affect individuals of all ages, including children, it poses unique challenges in pediatric patients. The severity of aortic stenosis in children can vary widely, ranging from mild to severe, and may present with symptoms such as chest pain, fatigue, and shortness of breath. If left untreated, aortic stenosis can lead to significant complications and negatively impact a child's overall health and quality of life.
Material and methods: Between February 2019 and June 2023, 38 patients were operated due to aortic valve pathologies in our hospital. Aortic valve repair was performed in 11 of these patients, and aortic valve replacement was performed in 27 patients. Patients' age, gender, body weight, aortic valve pathology, etiology of aortic valve pathology (congenital, rheumatic, infective endocarditis), presence of Marfan Syndrome, previous operation history, aortic annulus diameter, type of valve used, valve size, type of root enlargement if performed, cardiopulmonary bypass duration, cross-clamp duration, duration of intensive care unit stay, duration of ward stay, inotrope requirement, duration of inotrope use, mechanical ventilation duration, volume of drainage and mortality were retrospectively searched from patient files and hospital database.
Results: The median age of the patients was 12.96±3.38 (IQR=11.00-16.00) years, their weights ranged between 43.81±14.21 kilograms. Eight patients were female (29.6%) and 19 patients were male. (70.4%) The diagnosis was aortic stenosis in 8 patients (29.6%), aortic insuffiency in 9 patients (33.3%) and both aortic stenosis and insuffiency in 10 patients.(37%) The aortic annulus diameters of the patients were 21.59±4.64 mm. Anterior or posterior root enlargement was performed in 11 patients (40.7%) due to narrow aortic annulus. The Nick procedure was applied to 7 patients (63.6%), the Manoughian procedure to 2 patients (18.2%), and the Konno procedure to 2 patients (18.2%). Considering the mechanical aortic valve dimensions used in the patients, 5 patients had size 19 prosthetic aortic valve (18.5%), 8 patients had size 21 prosthetic aortic valve (29.6%), 8 patients had size 23 prosthetic aortic valve (29.6%), and 6 patients had size 25 prosthetic aortic valve (22.2%) were used. Mortality was observed in 3 patients.(11.1%) Causes of mortality can be listed as low cardiac output, neurological events and sepsis.
Conclusion: The ultimate goal is to ensure that children who undergo aortic valve replacement can lead healthy and fulfilling lives. By continually refining our approaches and learning from each case, we can make significant strides in the treatment of aortic valve issues in children and offer them the best possible outcomes.
Aortic valve replacement in children requires a multidisciplinary approach, with a focus not just on the surgical procedure itself but also on long-term management and support. With ongoing advancements and a collaborative mindset, we can continue to improve the care provided to these young patients and help them thrive.

Keywords

aortic valve replacement, aortic stenosis, aortic regurgitation, aortic root enlargement

References

• Etnel JR, Elmont LC, Ertekin E, Mokhles MM, Heuvelman HJ, Roos-Hesselink JW, et al. Outcome after aortic valve replacement in children: A systematic review and meta-analysis. J Thorac Cardiovasc Surg. 2016 Jan;151(1):143-52.e1-3.
• Akins CW, Miller DC, Turina MI, Kouchoukos NT, Blackstone EH, Grunkemeier GL, et al. Guidelines for reporting mortality and morbidity after cardiac valve interventions. Ann Thorac Surg. 2008 Apr;85(4):1490-5.
• Brown JW, Ruzmetov M, Vijay P, Rodefeld MD, Turrentine MW. Surgery for aortic stenosis in children: a 40-year experience. Ann Thorac Surg. 2003 Nov;76(5):1398-411.
• Takkenberg JJ, Kappetein AP, van Herwerden LA, Witsenburg M, Van Osch-Gevers L, Bogers AJ. Pediatric autograft aortic root replacement: a prospective follow-up study. Ann Thorac Surg. 2005 Nov;80(5):1628-33.
• Van Doorn C, Yates R, Tunstill A, Elliott M. Quality of life in children following mitral valve replacement. Heart 2000; 84: 643-647.
• Shanmugam G, MacArthur K, Pollock J. Mechanical aortic valve replacement: long-term outcomes in children. J Heart Valve Dis 2005; 14: 166-171.
• Hamasaki A, Yaqinuma G. Advantage of supra-annular patch enlargement in aortic stenosis with a small aortic annulus. Kyobu Geka 2006; 59: 289-293.
• Alsoufi B, d'Udekem Y. Aortic valve repair and replacement in children. Future Cardiol. 2014 Jan;10(1):105-15.
• Lindman BR, Dweck MR, Lancellotti P, Généreux P, Piérard LA, O'Gara PT, et al. Management of Asymptomatic Severe Aortic Stenosis: Evolving Concepts in Timing of Valve Replacement. JACC Cardiovasc Imaging. 2020 Feb;13(2 Pt 1):481-493.
• Roy N, Parra MF, Brown ML, Sleeper LA, Carlson L, Rhodes B, et al. Enhancing Recovery in Congenital Cardiac Surgery. Ann Thorac Surg. 2022 Nov;114(5):1754-1761.
• Fuller SM, Borisuk MJ, Sleeper LA, Bacha E, Burchill L, Guleserian K, et al. Mortality and Reoperation Risk After Bioprosthetic Aortic Valve Replacement in Young Adults With Congenital Heart Disease. Semin Thorac Cardiovasc Surg. 2021 Winter;33(4):1081-1092.
• Turrentine MW, Ruzmetov M, Vijay P, Bills RG, Brown JW. Biological versus mechanical aortic valve replacement in children. Ann Thorac Surg 2001; 7(suppl): s356-s360.
• Khitin LM, Sade RM, Bradley SM, Crawford FA Jr, Widener CE, et al. Prevention of thrombosis and embolism in children and adolescents with mechanical valve prostheses: warfarin versus antiplatelet agents. J Heart Valve Dis. 2006 May;15(3):394-9.