Surgical Implantation of Melody Valve in Mitral Position in Infants and Small Children: Toronto SickKids Method

In infants and small children with critical mitral valve disease nonamenable to repair is a high-risk population with high mortality after mechanical mitral valve replacement (MVR). Placement of the Melody™ valve (Medtronic, Minneapolis, MN, USA) in the mitral position has emerged as a palliative surgical strategy that provides time for somatic growth, until mechanical MVR becomes an appropriate option. Advantages of the Melody valve include its excellent early hemodynamics, no necessary extensive anticoagulation, and relative ease of implantation. Valve sizing is determined by preoperative echocardiography and intraoperative Hegar insertion. Toronto Melody valve modification includes a polytetrafluoroethylene skirt for anchoring to the mitral annulus and a large wedge resection of the stent to prevent left ventricular outflow tract obstruction. Once implanted and tied in standard fashion to conventional MVR, serial balloon dilations are performed to ensure that the valve is well expanded along the length of the stent. Left atrial augmentation may be required to ensure the valve is not obstructing pulmonary vein orifices. Our experience suggests that close surveillance for structural valve deterioration is imperative beyond 2-years post-implantation. In summary, the Melody valve is a safe and efficient temporizing strategy for infants requiring MVR.