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which by chance occurred while receiving maintenance treatment with heparin&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">A pregnant woman was referred to our hospital for foetal cardiomegaly at 36 weeks&#8217; gestation&#46; Assessment revealed global cardiomegaly&#44; severe tricuspid insufficiency and moderate mitral insufficiency with normal ventricular function and a closed foramen ovale &#40;FO&#41;&#46; Premature closure of the FO was diagnosed that required urgent surgery&#46; The neonatal echocardiogram confirmed these findings&#44; with the most salient feature corresponding to a highly dysplastic mitral valve with pulmonary pressures exceeding systemic pressures&#46; The patient did not respond well to treatment and was transferred to the surgical department at age 8 days&#46; Conservative measures were attempted unsuccessfully&#44; so at age 40 days the dysplastic &#40;myxomatous&#41; mitral valve was resected and a 16<span class="elsevierStyleHsp" style=""></span>mm mechanical prosthetic mitral valve placed in the supra-annular position &#40;CarboMedics&#44; Sorin Group<span class="elsevierStyleSup">&#174;</span>&#41;&#46; The patient had a cerebral infarction at the level of the middle cerebral artery as a complication of surgery&#46; The patient was kept under anticoagulant therapy with heparin&#44; administered by the subcutaneous route given his age&#46; At age 3 months he developed a severe pulmonary oedema secondary to the immobilization of the leaflets by pannus formation&#44; requiring a prosthesis exchange&#46; At age 11 months he had a new episode and underwent surgery again for resection of the pannus and thrombi&#44; and the prosthesis was cleaned and rotated after failure of treatment with fibrinolytic agents&#46; Treatment with acenocoumarol and acetylsalicylic acid &#40;ASA&#41; was initiated after the surgery&#46; The patient has remained asymptomatic since&#44; and is currently 3 years old&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Infant aged 5 months with no relevant history referred by his paediatrician for investigation of a heart murmur and growth failure&#46; The echocardiogram showed severe MI with a retracted posterior leaflet&#44; thickening of the free edge&#44; and significant dysplasia of the subvalvular apparatus with dysfunction of the left ventricle&#46; It also revealed retrograde flow in the left coronary artery&#44; suggestive of anomalous origin of the left coronary artery from the pulmonary artery &#40;ALCAPA syndrome&#41;&#46; This suspicion led to transfer of the patient to the reference hospital&#44; where the diagnosis was confirmed and coronary translocation from the pulmonary artery to the aorta performed along with a mitral valvuloplasty&#46; At 24 days he showed clinical worsening&#44; and underwent surgery again for placement of a mechanical mitral prosthesis &#40;CarboMedics 18&#44; Sorin Group<span class="elsevierStyleSup">&#174;</span>&#41;&#46; Treatment with heparin was initiated&#46; Six months later&#44; he had a sudden worsening of symptoms with signs of pulmonary oedema&#44; and investigation confirmed the immobilization of the valve leaflets&#46; A new intervention was performed&#44; with resection of the pannus and cleaning and rotation of the prosthesis&#46; The patient was subsequently put on acenocoumarol and ASA&#46; The patient&#44; currently aged 3 years&#44; remains asymptomatic&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The surgical management of MI poses a challenge to the paediatric surgeon due to its considerable complexity&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">3</span></a> Valve repair is the first-line treatment&#44; as it has the best outcomes&#44; although it is not always feasible&#46; Biologic prostheses have the advantage of not requiring anticoagulant therapy&#44; but they degenerate faster&#46; When it comes to mechanical prostheses&#44; the literature has identified the size of the ring and the position of the valve &#40;supra-annular or annular&#41; as factors that influence survival and the need for early reintervention &#40;stenosis&#44; endocarditis and thrombosis&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">2</span></a> It is imperative that patients are treated with vitamin K antagonist anticoagulants after the surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">4</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">In our patients&#44; treatment with heparin was chosen because the adherence to oral administration is worse in children younger than 12 months&#46; Pannus formation &#40;a fibrous tissue overgrowth&#41; was the reason for early reintervention in both patients&#46; This complication is uncommon in the paediatric literature&#46; Although it does not seem to be related to anticoagulant therapy&#44; in both of our patients it developed while they were undergoing treatment with heparin&#44; and did not recur when the patients were treated with a combination of a coumarin drug and ASA&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">In short&#44; MI in the paediatric age group continues to be a challenge&#46; Mechanical prostheses have the disadvantage of requiring chronic anticoagulant therapy&#44; which is difficult to adhere to&#44; especially in infants&#46;</p></span>"
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Scientific Letter
Mitral valve replacement in infants less than 6 months-old
Prótesis mitral en pacientes de menos de 6 meses
M. Colom Seguía,
Corresponding author
marinacolomsegui@gmail.com

Corresponding author.
, S. Escribà Borib, M.A. de la Fuente Sánchezb, F. García Algasb
a Servicio de Pediatría, Hospital Universitari Son Espases, Palma de Mallorca, Spain
b Unidad de Cardiología, Servicio de Pediatría, Hospital Universitari Son Espases, Palma de Mallorca, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Congenital mitral insufficiency &#40;MI&#41; is rare in children&#46; It is usually associated with other heart malformations&#44; and the isolated form occurs much less frequently&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">1</span></a> Mitral valve replacement &#40;MVR&#41; is an uncommon procedure in the paediatric age group&#44; especially in infants&#46; The most frequent indications for MVR are rheumatic disease&#44; endocarditis&#44; Shone syndrome or a failed atrioventricular canal repair&#46; Despite surgical advances and the use of different materials&#44; MVR is a complex surgery associated with a high rate of complications&#44; and is the procedure for mitral repair that carries the highest mortality &#40;5&#8211;52&#37;&#41; and the worst prognosis&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We present the cases of two patients that received care in our hospital and required MVR before age 12 months and reintervention shortly after&#44; which by chance occurred while receiving maintenance treatment with heparin&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">A pregnant woman was referred to our hospital for foetal cardiomegaly at 36 weeks&#8217; gestation&#46; Assessment revealed global cardiomegaly&#44; severe tricuspid insufficiency and moderate mitral insufficiency with normal ventricular function and a closed foramen ovale &#40;FO&#41;&#46; Premature closure of the FO was diagnosed that required urgent surgery&#46; The neonatal echocardiogram confirmed these findings&#44; with the most salient feature corresponding to a highly dysplastic mitral valve with pulmonary pressures exceeding systemic pressures&#46; The patient did not respond well to treatment and was transferred to the surgical department at age 8 days&#46; Conservative measures were attempted unsuccessfully&#44; so at age 40 days the dysplastic &#40;myxomatous&#41; mitral valve was resected and a 16<span class="elsevierStyleHsp" style=""></span>mm mechanical prosthetic mitral valve placed in the supra-annular position &#40;CarboMedics&#44; Sorin Group<span class="elsevierStyleSup">&#174;</span>&#41;&#46; The patient had a cerebral infarction at the level of the middle cerebral artery as a complication of surgery&#46; The patient was kept under anticoagulant therapy with heparin&#44; administered by the subcutaneous route given his age&#46; At age 3 months he developed a severe pulmonary oedema secondary to the immobilization of the leaflets by pannus formation&#44; requiring a prosthesis exchange&#46; At age 11 months he had a new episode and underwent surgery again for resection of the pannus and thrombi&#44; and the prosthesis was cleaned and rotated after failure of treatment with fibrinolytic agents&#46; Treatment with acenocoumarol and acetylsalicylic acid &#40;ASA&#41; was initiated after the surgery&#46; The patient has remained asymptomatic since&#44; and is currently 3 years old&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Infant aged 5 months with no relevant history referred by his paediatrician for investigation of a heart murmur and growth failure&#46; The echocardiogram showed severe MI with a retracted posterior leaflet&#44; thickening of the free edge&#44; and significant dysplasia of the subvalvular apparatus with dysfunction of the left ventricle&#46; It also revealed retrograde flow in the left coronary artery&#44; suggestive of anomalous origin of the left coronary artery from the pulmonary artery &#40;ALCAPA syndrome&#41;&#46; This suspicion led to transfer of the patient to the reference hospital&#44; where the diagnosis was confirmed and coronary translocation from the pulmonary artery to the aorta performed along with a mitral valvuloplasty&#46; At 24 days he showed clinical worsening&#44; and underwent surgery again for placement of a mechanical mitral prosthesis &#40;CarboMedics 18&#44; Sorin Group<span class="elsevierStyleSup">&#174;</span>&#41;&#46; Treatment with heparin was initiated&#46; Six months later&#44; he had a sudden worsening of symptoms with signs of pulmonary oedema&#44; and investigation confirmed the immobilization of the valve leaflets&#46; A new intervention was performed&#44; with resection of the pannus and cleaning and rotation of the prosthesis&#46; The patient was subsequently put on acenocoumarol and ASA&#46; The patient&#44; currently aged 3 years&#44; remains asymptomatic&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The surgical management of MI poses a challenge to the paediatric surgeon due to its considerable complexity&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">3</span></a> Valve repair is the first-line treatment&#44; as it has the best outcomes&#44; although it is not always feasible&#46; Biologic prostheses have the advantage of not requiring anticoagulant therapy&#44; but they degenerate faster&#46; When it comes to mechanical prostheses&#44; the literature has identified the size of the ring and the position of the valve &#40;supra-annular or annular&#41; as factors that influence survival and the need for early reintervention &#40;stenosis&#44; endocarditis and thrombosis&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">2</span></a> It is imperative that patients are treated with vitamin K antagonist anticoagulants after the surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">4</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">In our patients&#44; treatment with heparin was chosen because the adherence to oral administration is worse in children younger than 12 months&#46; Pannus formation &#40;a fibrous tissue overgrowth&#41; was the reason for early reintervention in both patients&#46; This complication is uncommon in the paediatric literature&#46; Although it does not seem to be related to anticoagulant therapy&#44; in both of our patients it developed while they were undergoing treatment with heparin&#44; and did not recur when the patients were treated with a combination of a coumarin drug and ASA&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">In short&#44; MI in the paediatric age group continues to be a challenge&#46; Mechanical prostheses have the disadvantage of requiring chronic anticoagulant therapy&#44; which is difficult to adhere to&#44; especially in infants&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Colom Segu&#237; M&#44; Escrib&#224; Bori S&#44; de la Fuente S&#225;nchez MA&#44; Garc&#237;a Algas F&#46; Pr&#243;tesis mitral en pacientes de menos de 6 meses&#46; An Pediatr &#40;Barc&#41;&#46; 2016&#59;84&#58;170&#8211;171&#46;</p>"
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                            1 => "F&#46; Roubertie"
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                      "autores" => array:1 [
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                          "etal" => true
                          "autores" => array:6 [
                            0 => "D&#46; Kalfa"
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                            2 => "M&#46; Ly"
                            3 => "B&#46; Stos"
                            4 => "V&#46; Lambert"
                            5 => "A&#46; Baruteau"
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                    ]
                  ]
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                0 => array:2 [
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                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "B&#46; Alsoufi"
                            1 => "C&#46; Manlhiot"
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                            4 => "A&#46; Kalloghlian"
                            5 => "G&#46; Siblini"
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        "texto" => "<p id="par0040" class="elsevierStylePara elsevierViewall">We want to thank the family members of the patients for their cooperation&#46;</p>"
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ISSN: 23412879
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