How to Construct an Autologous Pericardial Mitral Valve for Infants and Small Children

In this video, viewers will learn how to construct an autologous pericardial mitral valve for infants and small children when repair is not possible. 

The technique offers a durable solution by utilizing the patient’s own living tissue, thereby avoiding the risks of degeneration and calcification associated with chemically treated or prosthetic valves. While some long-term changes such as shrinkage or thickening may occur, these can be mitigated by intentionally oversizing the pericardial valve. Although reoperation may eventually be needed, this approach provides an important intervention-free period until the child grows enough to receive an adult-sized valve. This technique is similar to the procedure used with the right atrial appendage valve (RAA valve) for right-sided valves (1); however, the authors prefer the pericardium for the high-pressure left side due to its more resistant nature. 

The method is straightforward, reproducible, and does not significantly prolong operative time. Valve function is confirmed intraoperatively with a water test, and postoperative function is verified with echocardiography. 

The patient was an 8-month-old boy weighing 7 kilograms who presented with failure to thrive and respiratory distress requiring prolonged intubation. Echocardiography revealed severe mitral regurgitation due to thickened, myxomatous leaflets with restricted motion caused by shortened, fused chordae. The left atrium and ventricle were markedly dilated with impaired function.  

Intraoperative findings confirmed these observations and also identified anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA), along with evidence of ischemic injury to the left ventricle.  

The ALCAPA was repaired first by reimplanting the left coronary artery into the aorta. Attention then turned to the mitral valve, which showed organic pathology unsuitable for repair; the leaflets were severely thickened with abnormal chordal attachments.  

The decision was made to proceed with autologous pericardial valve replacement. A length of pericardium was selected that was larger than the calculated circumference of the annulus, while the height of the pericardial strip matched the annular diameter. The pericardium was fashioned into a tube using a double row of continuous CV-5 Gore-Tex sutures. Additional sutures were placed to create symmetrical commissures and form a bileaflet valve structure. 

Since the pericardial leaflets were longer than native ones, artificial chordae were anchored to Teflon pledgets placed deep in the ventricle near the apex. The chordal length was precisely adjusted using the adjustable pericardial lock technique (2) during water testing to optimize valve geometry. 

Postoperative assessment showed excellent valve function with symmetrical leaflet motion and no stenosis or regurgitation. The design incorporates a generous coaptation zone and slight leaflet billowing to maintain competence, even with potential future annular dilation as the child grows. Echocardiography at three months confirmed sustained valve performance with no complications. 

This technique provides a valuable option for mitral valve replacement in small children, using the patient's own tissue to create a functional valve that can adapt to growth while avoiding the limitations of prosthetic valves. Although it is probably not permanent, it serves as an important bridge to eventual definitive treatment. 

References

1. Amirghofran AA. Tricuspid Valve Replacement with the Right Atrial Appendage Valve: The First Report. Ctsnetorg. Published online November 28, 2023. doi:https://doi.org/10.25373/ctsnet.24650022
2. Amirghofran AA. Adjustable Pericardial Lock Technique for Complex Mitral Valve Repair. Ctsnetorg. Published online October 17, 2019. doi:https://doi.org/10.25373/ctsnet.9955976

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