Melody Mitral Valve Replacement Is No Longer an Experimental Procedure

nreconstructable mitral valve disease in the infant or child is not as rare as would be hoped.We have all had the 6-month-old with significant residual insufficiency after difficult AV canal repair or the 5 kg patient with persistent and severe mitral stenosis, despite repeated attempts to repair a dysplastic mitral arcade or parachute mitral valve.These patients have few remaining options, often failing to wean from mechanical ventilation with poorly compensated heart failure, despite maximal medical therapy.Although the potential for more esoteric approaches, such as combined mitral-aortic annular enlargement, placement of a Contegra conduit in the mitral position, 1 conversion to a single ventricle strategy, or even the Ross II operation in larger patients can be considered at specialized centers, the reality is that replacement of the mitral valve with a mechanical prosthesis is likely to be the best option in most centers.This is particularly the case when the annular size is sufficient to accept a valve of at least 17 mm.However, what is the appropriate course of action for those patients who need valve replacement but in whom the surgical options are limited to a less ideal 15 mm or even 17 mm prosthesis that must be placed in the supraannular position?What about the very small infant for whom no mechanical prosthesis can realistically be placed regardless of size or position?In the accompanying article in Circulation: Cardiovascular Interventions, Pluchinotta et al 2 make a strong and cogent argument that in these situations, consideration should be given to the use of the stented bovine jugular vein graft (Melody valve) in the mitral position.This cohort study included 68 patients treated at 17 institutions, the youngest of whom underwent valve implantation at 3 days of life.Freedom from mortality or transplantation was 72% at 2 years, despite the fact that most of the early deaths (6 of 8) occurred as attempts to salvage patients from extracorporeal membrane oxygenation support, and all 3 transplant recipients had their valve as a planned bridge to transplantation.A majority of the late deaths (4) also occurred in patients receiving a tricuspid replacement, at least some of whom were systemic AV valves in children with single ventricle anatomy.I think that for the seriously ill child that has failed medical management and whose mitral annular size precludes any surgical options, this technique represents a clear advance, offering a therapeutic option where there was not one previously.Whether or not the Melody should be offered in lieu of either a marginally sized or suboptimally positioned mechanical valve remains an issue that is best left to the individual surgeon and cardiologist.However, the evidence we now have suggests that the Melody valve in the mitral position is safe, effective, and reproducible.At least in the short term, the morbidity and mortality risks are comparable to that of a mechanical prosthesis. 3,4The technical aspects of placing the valve are not highly demanding, there is the potential to enlarge the valve to match somatic growth,