Five- to fifteen-year follow-up of fresh autologous pericardial valved conduits

OBJECTIVE: Evaluate long-term results of autologous pericardial valved conduits in the pulmonary outflow. METHODS: Between June 1983 and October 1993, 82 conduits were placed in the outflow of the venous ventricle. Patients who received homografts (n = 2 patients), heterografts (n = 3 patients), and valveless conduits (n = 19 patients) and those patients who died within 90 days after the operation were excluded. Fifty-four survivors of pulmonary outflow reconstruction with fresh autologous pericardial valved conduits were followed up from 5 to 15 years (mean, 7.47 +/- 2.8 years). Diagnosis include d -transposition of great arteries (n = 16 patients), L -transposition of great arteries (n = 14 patients), tetralogy of Fallot, pulmonary atresia with ventricular septal defect (n = 11 patients), truncus arteriosus (n = 10 patients), and double-outlet ventricle (n = 3 patients). Implantation age ranged from 0.25 to 24 years (mean, 5.2 +/- 4.2 years). Median conduit diameter was 16 mm. Two-dimensional echocardiographic Doppler evaluations were made yearly; 9 patients underwent cardiac catheterization. Reintervention for stenosis was indicated when the pressure gradient exceeded 50 mm Hg. RESULTS: Three late deaths were unrelated to the conduit. Thirty-five autologous pericardial valved conduits increased in diameter (1-7 mm), remained unchanged in 15 patients, and reduced 1 to 2 mm in 4 patients. The median diameter was 18 mm at the last evaluation (P =.0001). Eight patients required conduit-related reoperation 3 to 8 years after the implantation. Two patients underwent balloon dilation of the autologous pericardial valved conduit. No conduit had to be replaced. Freedom from reintervention at 5 and 10 years was 92% and 76%, being 100% at 10 years for conduits larger than 16 mm at time of implantation. CONCLUSIONS: Autologous pericardial valved conduits show excellent long-term results and compare favorably with other conduits.     

Unsatisfactory Clinical Experience with a Collagen-Sealed Knitted Dacron Extracardiac Conduit

A clinical trial of a collagen-sealed knitted Dacron conduit (Tascon Medical Technologies) in 86 patients has revealed a high incidence of early reoperation for conduit stenosis. At 3 years, the actuarial incidence of freedom from conduit replacement was 67 +/- 14% for valved conduits, and 66 +/- 20% for nonvalved conduits. Seven of eight conduits that were replaced had a thick, weakly adherent pseudointima. Comparison of the current series with a previous series of patients receiving tightly woven low-porosity Dacron conduits is complicated by the young age, small size, and greater complexity of the current group. Nevertheless, the findings are consistent with the results of two laboratory studies performed at this hospital which suggest that the collagen used in the Tascon conduit undergoes particularly slow resorption, resulting in weak adhesion between the pseudointima and conduit. This allows hemorrhagic dissection to occur deep to the pseudointima. These data suggest that alternative methods of sealing knitted Dacron conduits should be used.     

Extracardiac valved conduits in the pulmonary circuit

Extracardiac valved conduits represent one of the weakest facets of reconstructive surgery for congenital heart disease in that they invariably need to be replaced because of growth of the patient or because of valve or conduit failure. Between 1979 and 1989, 141 patients had 169 valved conduits placed between the heart and the pulmonary artery circuit. There were 81 male and 60 female patients, aged 2 days to 35 years (mean age, 5.9 years), with 46 patients less than 1 year of age. We performed primary repair in 117 patients; in this group, there have been 28 conduit replacements in 27 patients. In 17 patients initial repair with a conduit was performed elsewhere and we replaced these conduits in 15 and removed them in 2. A further group of 9 patients were seen after repair of tetralogy of Fallot or double-outlet right ventricle, with severe pulmonary incompetence or right ventricular outflow tract aneurysm. All had valved conduits inserted as secondary procedures. The types of valved conduits used were xenograft (n = 126) and homograft (n = 43). There were six hospital deaths (3.6%; 70% confidence limits [CL], 2% to 6%) and seven late deaths (4.1%; CL, 2.5% to 6.5%) in a total of 169 conduit insertions. Forty-five conduits have been removed and 43 reinserted without early or late mortality (0%; CL, 0% to 4%). Actuarial survival after conduit insertion was 87% at 5 years (CL, 80% to 92%), including operative mortality. Actuarial freedom from conduit replacement was 37% at 5 years (CL, 20% to 56%). Conduit insertion in infants and small children ensures subsequent replacement, but this can be done at low risk.(ABSTRACT TRUNCATED AT 250 WORDS)     

Repeat median sternotomy in pediatrics: experience in 164 consecutive cases

One hundred thirty-eight children underwent 164 operations through repeat median sternotomy. Ages ranged from 4 months to 21 years (mean, 8.6 +/- 5.0 years). The technique consisted of opening the sternum with chisel and mallet, avoidance of sudden separation of sternal edges and blunt dissection, elimination of the electrocautery during lysis of adhesions, and judicious use of fresh blood and components. Several variables were analyzed comparing the initial and repeat procedures on each patient. Time from incision to bypass was an hour longer with the repeat procedure (174 +/- 45 minutes versus 96 +/- 37 minutes). Operative transfusions and postoperative bleeding (first 48 hours) were not significantly different between the two procedures. Cyanosis, however, significantly increased bleeding in both groups. There were eight injuries (5%) at reoperation. During sternal reentry in 2 patients, a tear occurred in a valved conduit coursing underneath the sternum. A right ventricular tear occurred in 1 patient while the sternal edges were being separated. Ventricular fibrillation was noted in 2 patients during lysis of adhesions with the electrocautery used early in the series. Intimal disruption occurred in two valved conduits during intraoperative manipulations. An aortic tear occurred and was repaired without cardiopulmonary bypass. There were 13 (8%) hospital deaths, all unrelated to the technique. We believe that the current approach can be a valuable alternative for surgeons dealing with repeat median sternotomy in children.     

Xenograft transplantation in congenital cardiac surgery at Baskent University: midterm results

OBJECTIVE: Xenograft valved conduits have been used in several cardiac pathologies. In this study we have presented our midterm results of pediatric patients pathologies who were operated with xenograft conduits. PATIENTS AND METHODS: Between January 1999 and January 2005, 134 patients underwent open heart surgery with xenograft conduits. The conduits were used to establish the continuity of the right ventricle to the pulmonary artery or aorta, the left ventricle to the pulmonary artery, or aorta due to various types of complex cardiac anomalies. Patients were evaluated by transthoracic echocardiography (ECHO) at 6-month follow-ups. Cardiac catheterization was performed when ECHO demonstrated significant conduit failure. RESULTS: Hospital mortality was observed in 28 patients (20.1%), and 13 patients died upon follow-up (9.7%). Mean follow-up was 24.6 +/- 4 months (range, 13 to 85 months). Among 93 survivors 20 patients (21.5%) were reoperated due to conduit failure. The main reasons for conduit failure were stenosis (n=13), valvular regurgitation (n=2), or both conditions in 5 cases. Mean pulmonary gradient before conduit re-replacement was 47.7 +/- 30.1 mmHg. The 1-, 3-, and 6-year actuarial survival rates were 95 +/- 2%, 91 +/- 3%, and 86 +/- 5%. The 1-, 3-, and 6-year actuarial freedom rates from reoperation were 95 +/- 1%, 90 +/- 3%, and 86 +/- 4%. An increased gradient between the pulmonary artery and the right ventricle and prolonged cardiopulmonary bypass times were observed to be significant risk factors for reoperation. There was no mortality among reoperated patients. CONCLUSION: Xenograft conduits should be closely followed for calcification and stenosis. Conduit stenosis is the major risk factor for reoperation. In these patients, reoperation for conduit replacement can be performed safely before deterioration of cardiac performance.     

Total repair for truncus arteriosus]

Total repair for truncus arteriosus using an external conduit was performed in 12 patients from 1978 through 1989. Six cases were infants (mean age: 3.4 months) and 6 were children (mean age; 1 years 9 months). Two cases had Collet-Edwards type II truncus and the other 10 cases had type I truncus. One of the infants was associated with an interruption of the aorta and another had a severe regurgitation of the truncal valve (TrV). For external conduits, we used a non-valved conduit in one infant, a composite valved conduit of Dacron containing a heterograft valve in 4 children and a valved pericardial roll made of an autologous or porcine pericardium in 5 infants and 2 children. One infant with a severe regurgitation of the TrV needed valve replacement along with enlargement of the annulus of the TrV. One infant who had replacement of the TrV died early postoperatively. Another infant died 10 months after total repair due to an infection of an external conduit. Cardiac catheterization was performed in all 10 survivors. The mean value for the systolic pulmonary/systemic pressure ratio decreased from 0.98 +/- 0.09 preoperatively to 0.36 +/- 0.09 postoperatively. Replacement of an external conduit was performed due to a conduit stenosis in 2 children and 1 infant, 10 years and 2 months, 7 years and 9 months, and 1 year and 8 months after the total repair, respectively. In one of these 2 children, replacement of the aortic valve was performed due to a severe aortic regurgitation. We conclude that our results of total repair for truncus arteriosus were satisfactory. However, it remains to be solved how to manage an infant with truncus arteriosus associated with a severe regurgitation of the TrV.     

Reoperation for double-outlet right ventricle (SDL type) following the Rastelli procedure: report of a case

The relationship of the conduit to the sternum is crucial in the Rastelli operation. Right-sided conduits are more greatly affected by sternal compression than left, since the position of the right ventricular infundibulum is more anterior. A 37-year-old woman developed right ventricular outflow tract obstruction, left ventricular outflow tract obstruction, and aortic valve regurgitation secondary to infective endocarditis 15 years after Rastelli repair for double-outlet right ventricle (SDL). We enlarged the ventricular septal defect, performed intraventricular rerouting and aortic valve replacement, and reconstructed the valved conduit using a Carpentier-Edwards conduit. The old conduit was densely adherent to the sternum. Subaortic stenosis was caused by a narrow fibromuscular ridge associated with a bulge of the underlying septal muscle. The patient's recovery was uneventful. She is alive and well without any complaints 1 year after surgery.     

Right atrioventricular extracardiac conduit as a fontan modification: late results

BACKGROUND: The right ventricle, when incorporated in the Fontan circulation, might enlarge and function as a pump to the pulmonary circulation. Experience has shown that over the long-term, this operation can be associated with major difficulties. METHODS: The late results, (13+/-6 years) after right atrioventricular connection as a Fontan modification, were reviewed in 14 patients with tricuspid atresia (11), ventricular septal-defect with small right ventricle (2), and double inlet left ventricle (1) to assess the long-term survival, the right ventricular size, and the need and timing of reoperations. Operations used a valved conduit (7), a valveless Dacron (E.L. Bard, Haverhill, PA) tube (5) and a direct right atrium-right ventricle anastomosis (2). RESULTS: Death occurred in 5 by 8+/-5 years. Conduit obstruction occurred in 10 by 9+/-3 years equally in patients with valved (6 of 7) compared to patients with valveless conduits (4 of 5) and irrespective of right ventricular size (3 of 4 with enlarged right ventricle versus 4 of 6 with small ventricle). Patients with direct atrioventricular anastomosis had no obstruction. Reoperation was performed in 9 but failed to relieve the obstruction in 4 because of external compression (4) with or without thrombosis (1). CONCLUSIONS: Right atrioventricular connection as a Fontan modification can provide good early palliation, but is a poor long-term solution, as it is associated with a high incidence and difficulties in relieving the obstruction.     

Midterm results with cryopreserved allograft valved conduits from the right ventricle to the pulmonary arteries.

From 1985 to 1990, 89 patients underwent placement of 41 aortic and 54 pulmonic cryopreserved allograft valved conduits between the right ventricle and the pulmonary arteries. Six patients underwent replacement with a second allograft conduit. Median age at operation was 4.3 years, and 20 patients were infants less than 1 year of age. Conduit sizes averaged 11 mm in the conduits placed in 20 infants and 20 mm in the 75 placed in patients more than 1 year of age. There were 7 early deaths in 89 patients (7.8%, 70% confidence levels 5.4% to 11.3%) and 9 late deaths in 82 hospital survivors (11%, 70% confidence levels 8% to 15%). Actuarial survival was 81% (70% confidence levels 75% to 86%) at 33 months, and no deaths were due to conduit problems. Late reoperation was required in 13 patients (7 for conduit obstruction, 1 for conduit valve insufficiency, and 5 for nonconduit-related problems). Six of the eight reoperations were done in patients who had small (< or = 13 mm) conduits placed during infancy. Conduit failure was similar between pulmonic and aortic allografts. There were no deaths in the eight patients who required conduit reoperation. Actuarial freedom from reoperation for conduit dysfunction was 80.5% (70% confidence levels 72% to 86%) at 53 months for the entire group and 94% (confidence levels 88% to 97%) at 44 months for patients more than 1 year of age. Cryopreserved allograft conduits have good early and midterm results and are comparable to porcine xenograft conduits. Despite a likely need for replacement within 3 years, we continue to favor the use in infants of an allograft valved conduit over a xenograft Dacron conduit. The need to replace a cryopreserved allograft conduit appears similar for conduits of aortic or pulmonic origin.     

Intermediate-term fate of cryopreserved allograft and xenograft valved conduits

Actuarial freedom from reoperation for obstruction in 147 patients receiving cryopreserved or fresh allograft valved conduits between a ventricle and the pulmonary arteries was 94% at 3.5 years. The 2 patients undergoing reoperation were 6 and 36 months of age at the time of insertion of the allograft. Among 24 patients in whom cardiac catheterization was performed on indication late postoperatively, 5 had gradients of more than 40 mm Hg across the conduit. For comparison, among 78 patients receiving xenograft or irradiated allograft valved conduits, the percentages of freedom from conduit reoperation at 3.5, 5, 10, and 15 years were 99%, 95%, 59%, and 11%, respectively. The diameters of the allograft and xenograft valves inserted varied directly with the age and size of the patients, but in patients 3 to 5 years of age, allografts with a diameter of at least 21 mm could usually be used.     

Apicoaortic conduit for left ventricular outflow tract obstruction: revisited

BACKGROUND: We have used a variety of techniques to correct left ventricular outflow tract obstructions, including, in the past, placement of an apicoaortic valved conduit to bypass the outflow tract. Because the operation was technically difficult, it had fallen into disuse. Recently, we used a simplified transthoracic approach to implant apicoaortic conduits in 7 patients with complex lesions of the left ventricular outflow tract. METHODS: The thoracic cavity was entered through the fifth intercostal space in all 7 patients. The distal end of the valve-containing conduit was attached to the aorta with continuous 3-0 or 4-0 polypropylene sutures after incising the pleura over the distal descending aorta. The pericardium was opened to expose the left ventricular apex, which was cored so that the proximal end of the conduit could be inserted into the left ventricular cavity. RESULTS: Five of the patients recovered completely. The 2 patients who died had severe heart disease and multiple comorbidities. CONCLUSIONS: The transthoracic approach gives direct access to the descending aorta and avoids a redo sternotomy. The technique, which is simple to perform, does not compromise major coronary arteries, the conduction system, or other valves; and may be useful in patients who are not good candidates for other, more conventional procedures.     

Late Results of Reconstruction of the Right Ventricular Outflow Tract with Porcine Xenografts in Children

Thirty-three children, aged 2.5 to 17.5 years (mean, 8.3 years), having xenograft external conduits placed between the right ventricle and pulmonary artery were followed for 1 to 6 years postoperatively (mean, 3.5 years). There were no late deaths in the study group, and no infection of a valved conduit has been demonstrated. Twenty of these children were catheterized during the follow-up period. The gradients from the right ventricle to pulmonary artery ranged from 8 to 90 mm Hg (average, 31 mm Hg). A total of 8 patients were classified as having hemodynamically documented conduit failure, and an additional 2 patients are clinically expected to have conduit failure. This represents a total incidence of 30% xenograft conduit failure in a 6-year follow-up. Although the etiology of this dysfunction is probably multifactorial, factors such as valve size, conduit angulation, and immunological competence bear special consideration.We conclude that although valved external conduits continue to play an important role in the treatment of complex congenital heart disease, a valved conduit with greater longevity is needed for use in children.     

Externally stented polytetrafluoroethylene valved conduits for right heart reconstruction. An experimental comparison with Dacron valved conduits

Valve-containing conduits have made possible the repair of many congenital anomalies that involve right ventricular-pulmonary arterial discontinuity. The distressing problem of neointimal peel formation with eventual conduit obstruction in patients with Dacron valved conduits has led to the need for premature replacement in many patients. Externally stented polytetrafluorethylene has demonstrated superior patency in the venous system experimentally and clinically and was believed to have potential advantages over Dacron for conduit construction. This study compares the transconduit resistance and the thickness of the neointimal peel in right ventricular-pulmonary arterial conduits constructed of externally stented polytetrafluoroethylene with those of woven Dacron. The 19 mm externally stented polytetrafluoroethylene conduits (Impra, Inc.) containing a Hancock porcine valve (Extracorporeal Inc.) were implanted in six adult mongrel dogs followed by proximal occlusion of the pulmonary artery. In six additional animals, a Dacron valved conduit of similar size and length was inserted. Cardiac output, transconduit gradient, and resistance were measured at operation and at 3 months. All conduits were subsequently explanted, opened longitudinally, and the thickness of the neointimal peel (excluding suture lines) measured. No hemodynamic differences were noted during the 3 month follow-up. However, the thickness of the neointimal peel was fourfold greater in Dacron conduits (609 +/- 144 mu) than in the conduits constructed of externally stented polytetrafluoroethylene (156 +/- 50 mu) (p less than 0.01). The thick peel in Dacron conduits extended into the outflow portion of the porcine valve cusps and prevented their full excision. The neointima in externally stented polytetrafluoroethylene conduits was thin and uniform and did not extend onto the leaflets or limit their mobility. This study demonstrated that the early hemodynamic performance of externally stented polytetrafluoroethylene conduits was comparable to that of Dacron conduits; Dacron conduits were subject to an accelerated rate of peel formation that affected leaflet mobility and may be a factor in early valve degeneration; a thin neointima formed in externally stented polytetrafluoroethylene conduits and valve leaflet motion was preserved. This study showed that externally stented polytetrafluoroethylene conduits offer advantages over Dacron valved conduits and warrant clinical application.     

Right ventricular outflow tract reconstruction using Contegra valved conduit: natural history and conduit performance under pressure.

OBJECTIVE: To assess the performance of the bovine Contegra valved conduit used for right ventricular (RV) outflow tract reconstruction, particularly in relation to post-operative RV pressure. METHODS: Follow-up study of 64 consecutive right ventricular to pulmonary artery-conduit implants in 62 patients between January 2000 and April 2003. The majority of cases were forms of pulmonary atresia/VSD (n=24, 39%) or Fallot's tetralogy (n=13, 21%). Thirteen cases (21%) had aortic atresia, truncus arteriosus or discordant connections with pulmonary atresia/VSD. Twelve cases (19%) were conduit replacements. Echocardiography was performed for a median follow-up of 14 months (range 0-38 months). RESULTS: Median age at implantation was 13.8 months (range 0.1-244 months) and median weight was 8.9 kg (range 2.1-84.1 kg). Thirty-eight patients (59.4%) were <10 kg at the time of surgery. Early mortality was 6.4% (n=4). During follow-up there were four explantations (one for endocarditis and three for conduit dilatation) and 16 (28.6%) catheter interventions. Overall freedom from intervention at 1 and 3 years was 71+/-6% and 53+/-11%, respectively. Freedom from conduit-specific reintervention was 66+/-11% at the end of the study period. Reintervention was associated with small conduits (p=0.04), age <1 year (p=0.04) and with high RV/LV pressure ratio in the immediate post-operative period (p=0.0003). On multivariate analysis, the RV/LV pressure ratio was the strongest single factor predicting the overall reintervention (OR 5.45). Acquired distal conduit stenosis at suture line was the commonest indication for conduit-specific reintervention and was associated with the smaller conduits. The conduits explanted for dilatation showed neointimal proliferation, thrombosis, calcification and chronic inflammation. CONCLUSIONS: The Contegra conduit is widely applicable to RVOT reconstruction with satisfactory mid-term results. However, there is a significant incidence of conduit-related complications, particularly with the smaller conduits. Adverse performance was strongly associated with high RV/LV pressure ratio at completion of surgery. We would recommend cautious use of the conduits in patients with predicted high RV/LV pressure ratios, where careful monitoring of conduit performance is crucial. There is some element of unpredictability, which adds to the importance of close follow-up. Further studies are needed to explore the issues of thrombogenicity, degeneration, possible 'rejection', and the potential role of anti-platelet and anti-inflammatory modulation.     

儿童永存动脉干的外科治疗

目的　总结儿童永存动脉干外科治疗经验。　方法　近９ 年来共收治永存动脉干５例,年龄３～１２ 岁,平均６－３ 岁。Ⅰ型２ 例（肺动脉均起于动脉干远侧）,Ⅱ型２ 例, Ⅳ型１ 例。肺循环时间和肺动脉排空时间均无明显延长。手术在体外循环心内直视下进行,室间隔缺损（ＶＳＤ） 补片缝合于动脉干瓣环并使其环缩。右心外管道采用缝制自体新鲜心包瓣涤纶人工血管４ 例,同种异体主动脉１ 例。　结果　术毕肺动脉压均明显下降,跨外管道压差７～３５ ｍｍ Ｈｇ。２ 例术后早期死亡与肺动脉病变无关。存活３ 例中１ 例并发低心排出量和呼吸功能不全,２ 例术后恢复顺利。分别随访１１４、９６ 和３４ 个月,心功能均为Ⅰ级,１ 例术后８ 年死于外管道梗阻。　结论　儿童永存动脉干仍可有手术指征; 带自体心包瓣人工血管远期效果良好; 纠正动脉干瓣关闭不全,防止ＶＳＤ 残余漏,避免过大的跨外管道压差和缩短手术时间,可提高手术成功率和远期效果     

Long-term outcome of infrainguinal bypass grafting in patients with serologically proven hypercoagulability

OBJECTIVE: The purpose of this study was to test the hypothesis that the long-term outcome of infrainguinal bypass grafting in patients with congenital or acquired hypercoagulability is inferior to the results in patients without documented clotting disorders. METHODS: The study was a retrospective analysis of consecutive patients from January 1994 to January 2001. RESULTS: Five hundred eighty-two infrainguinal bypass grafts were created in 456 patients. Indication for surgery was limb-threatening ischemia in 84%; prosthetic conduits were implanted in 38%. Seventy-four grafts were created in 57 patients with one or more serologically proven hypercoagulable states, including heparin-induced platelet aggregation (n = 37), anticardiolipin antibodies (n = 11), lupus anticoagulant (n = 8), protein C or S deficiency (n = 7), antithrombin III deficiency (n = 3), and factor V Leiden mutation (n = 1). Patients with hypercoagulability were younger (63 +/- 2 years versus 69 +/- 1 years; P =.007), more likely to have undergone prior revascularization attempts (38% versus 21%; P =.003), and more likely to have chronic anticoagulation therapy after surgery (46% versus 25%; P =.001). After 5 years (median follow-up, 19 months), patients with hypercoagulability had poorer primary patency (28% +/- 7% versus 35% +/- 5%; P =.004), primary assisted patency (37% +/- 7% versus 45% +/- 6%; P =.0001), secondary patency (41% +/- 7% versus 53% +/- 6%; P =.0001), limb salvage (55% +/- 8% versus 67% +/- 6%; P =.009), and survival (61% +/- 8% versus 74% +/- 4%; P =.02) rates. Multivariate analysis identified only prosthetic conduit choice (P =.0001), hypercoagulability (P =.0003), and limb salvage indication (P =.01) as independent predictors of graft failure. CONCLUSION: Patients with serologically proven hypercoagulability have inferior long-term patency, limb salvage, and survival rates after infrainguinal bypass. The high prevalence rate (13%) of diverse hypercoagulable states in this patient population supports serologic screening, especially in referral practices.     

Early and late results of fresh autologous pericardial valved conduits

The objective of this study was to evaluate the early and late results of an autologous pericardial valved conduit in the pulmonary circulation. Between 1983 and 1997, 86 autologous pericardial valved conduits were used to achieve venous ventricle-pulmonary artery continuity. The mean patient age at the time of implantation was 4.16 ± 4.10 years (15 days to 24 years). All patients had two-dimensional postoperative and yearly Doppler echocardiograms in which the valve function and the presence of distal, valvar, and proximal stenosis were evaluated. There were 13 early deaths (15%). Twenty-one patients (24.4%) showed trivial, 54 (62.8%) mild, nine (10.4%) moderate, and two (2.3%) severe pulmonary regurgitation in the early postoperative period. The 73 survivors were monitored from 1 to 15 years (mean, 6.5 years; median, 7.1 years). There were five late deaths. The mean conduit diameter at the time of implantation was 15.8 mm, increasing to 18.21 mm at last evaluation (P < .0001). There were nine reoperations, with only one conduit replacement. Freedom from reintervention at 5 and 10 years was 89% and 80%, respectively. In conclusion, autologous pericardial valved conduits provide good early and excellent long-term results that compare favorably with those of other conduits. Copyright © 1999 by W.B. Saunders Company     

Long-term outcome of right ventricular outflow tract reconstruction using a handmade tri-leaflet conduit.

OBJECTIVE: Since 1985, we have implanted handmade tri-leaflet conduits made of heterologous pericardium or expanded polytetrafluoroethylene (ePTFE), as an alternative to homograft for right ventricular outflow tract reconstruction. This report assesses the long-term outcome of these prostheses. METHODS: From 1985 to 2003, 216 handmade tri-leaflet conduits were implanted in 191 patients. Forty-two patients had previous conduit repairs. The mean age at operation was 8.1+/-7.7 years (range: 15 days-44 years). The underlying diagnoses were pulmonary atresia with ventricular septal defect in 83 patients, atrioventricular discordance in 36, transposition of the great arteries in 26, double outlet right ventricle in 14, and truncus arteriosus in 17. Whole heterologous pericardial tri-leaflet conduits were implanted in 169 patients, in the early series (porcine: 85; equine: 58; bovine: 26); bovine pericardial conduits containing ePTFE leaflets were implanted in 26 patients since 1996; whole ePTFE tri-leaflet rolls were employed in the most recent 21 patients. The conduit size was 21.1+/-3.1mm (range: 12-27 mm), 147.4+/-21.4% (range: 82.6-202.6%) of the anticipated diameter of the pulmonary valve. Follow-up was complete. RESULTS: There were 28 early deaths and 24 late deaths. The indication for conduit replacement was a peak instantaneous pressure gradient of greater than 50 mmHg. Sixty-five conduits required reoperation for conduit obstruction at 8.6+/-3.3 years after implantation. The freedom from reoperation at 5, 10, and 15 years was 93.9+/-1.9, 61.4+/-4.5, and 35.5+/-5.6%, respectively. Patients with smaller conduit size and young age at operation were predisposed to reoperation. None of the 47 ePTFE tri-leaflet conduits developed significant obstruction. The freedom from important pulmonary valve regurgitation (PR) as assessed by echocardiography was 68.3+/-3.7% at 5 years, 33.0+/-4.5% at 10 years, and 21.6+/-4.9% at 15 years. No patient required reoperation due to PR or right ventricular dysfunction. CONCLUSIONS: Handmade tri-leaflet conduits provide a reliable alternative for RVOT reconstruction in children, yielding as good a long-term outcome as do homografts. Longer follow-up is needed to determine how well ePTFE leaflets will fare.     

The Autologous Pericardial Valved Conduit for Right Ventricular Outflow Tract Reconstruction

Between June 1983 and December 2002, 138 autologous pericardial conduits were placed in the pulmonary position. Diagnosis included D-transposition of great arteries (n = 45 patients), truncus arteriosus (n = 30), L-transposition of great arteries (n = 28), tetralogy of Fallot, pulmonary atresia with ventricular septal defect (n = 25), and double-outlet ventricle (n = 10). Implantation age ranged from 15 days to 24 years (mean 2.9 years). Median conduit diameter was 15 mm. There were 19 (13.7%) early deaths, Of the patients, 29% had trivial, 59% mild, 9% moderate, and 3% severe pulmonary regurgitation during the early postoperative period. The 119 survivors were monitored from 1 to 19 years (mean 9.8). There were 6 late deaths. Mean conduit diameter at implantation was 16 mm, increasing to 17.9 mm at last evaluation (P < 0.0001). There were 12 reoperations, with only 3 conduit replacements. Freedom from conduit related reintervention at 5, 10, and 15 years was 90%, 81%, and 77%, respectively. In conclusion, autologous pericardial valved conduits provide good early and excellent long-term results.     

Endovascular stent implantation for the management of postoperative right ventricular outflow tract obstruction: clinical efficacy.

OBJECTIVE: Extracardiac conduits between the right ventricle and pulmonary arteries commit patients to multiple reoperations. We reviewed our experience with stent implantation in obstructed conduits. METHODS: Between 1990 and 1997, stents were implanted across 43 conduits. The median age at procedure was 6 years (0.5-17 years), and the median interval between conduit insertion and stent implantation was 2.4 years (0.3-14 years). RESULTS: Mean systolic right ventricular pressures and gradients, respectively, decreased from 71 +/- 18 mm Hg and 48 +/- 19 mm Hg before to 48 +/- 15 mm Hg and 19 +/- 13 mm Hg after stent placement. Mean percentage of predicted valve area for body surface area increased from 26% +/- 12% to 48% +/- 17% after stent placement. Fifteen patients underwent a second transcatheter intervention (dilation or additional stent), and 2 patients, a third, allowing further postponement of surgery in 8 patients. One sudden death occurred 2.8 years after stent placement. Surgical conduit replacement has occurred in 20 patients. Body growth was maintained during follow-up. Freedom from surgical reintervention was 86% at 1 year, 72% at 2 years, and 47% at 4 years. Higher right ventricular pressure and gradient before and after stent placement and lower percentage of predicted valve area for body surface area after stent placement were associated with shorter palliation. CONCLUSION: Endovascular stent placement across obstructed conduits is a safe and effective palliation that allows for normal body growth.