Stented bovine jugular vein graft (Melody valve) for surgical mitral valve (MV) replacement in an infant

Case Report: A 4-month-old infant with Down syndrome and associated balanced atrioventricular septal defect (AVSD) developed congestive heart failure. It underwent surgical repair with one-patch technique and reconstruction of the dysplastic left-sided AV valve. Due to depressed ventricular function extracorporeal membrane oxygenation (ECMO) had to be initiated. Temporary DDD pacing was necessary for third-degree AV block. While cardiac function improved, severe mitral regurgitation (MR) persisted. Echocardiography revealed a leaking patch leading to recurrent ventricular (VSD) and atrial septal defect (ASD) with severe tricuspid regurgitation due to secondary pulmonary hypertension (PH). VSD and ASD were closed when ECMO was explanted. Nevertheless, due to persistent MR and PH, the infant was unable to be weaned from the ventilator. Since there are limited options for MV replacement in infants including mechanical and bioprosthetic valves, the Ross-II procedure, and the well-known problem of prostheses being neither small enough nor expandable as the child grows, we decided to implant a modified Melody valve in mitral position. The valve was subsequently dilated with a balloon from 8 to 12 mm. One-month post surgical course was uneventful and the infant was discharged in good condition. Echo showed no signs of LVOT, paravalvular leak, stenosis or insufficiency of the melody valve. Therefore we presume, that expandable Melody valve could be a good option for mitral valve replacement in critical ill newborns and infants.