Heart-Block Complicating Tricuspid-Valve Replacement In Children

Evaluation of pediatric patients following tricuspid valve replacement (TVR) with Hancock porcine heterograft valves indicated a high incidence of complete heart block (CHB). Eight patients who received Hancock valves in the tricuspid position were identified. Their ages ranged from one and one half to 18 years. All patients had insufficient tricuspid valves: three had Ebstein's anomaly, three with enlarged right ventricles underwent TVR three to eight years after repair of tetralogy of Fallot, one had congenital tricuspid insufficiency associated with ventricular septal defect and pulmonic stenosis, and one had tricuspid insufficiency associated with d-transposition and mitral atresia. All patients developed at least transient CHB after surgery, five required cardiac pacing, and the two youngest received permanent pacemakers. Four of eight patients died. One died from massive bleeding in the immediate postoperative period and another from disruption of the prosthetic valve by bacterial endocarditis one and one half months after surgery. One patient with a permanent pacemaker died suddenly three months after surgery, and another who did not require cardiac pacing died suddenly 22 months after surgery. The nature of the injury to the conduction system is unknown. It is clear that CHB can be expected to complicate TVR in pediatric patients, that temporary or permanent cardiac pacing may be required after surgery, and that the long term prognosis despite pacing is only fair.