Alternative to pulmonary allograft for reconstruction of right ventricular outflow tract in small patients undergoing the Ross procedure

Abstract

Small pulmonary allografts are difficult to obtain, thus we now use a tailor-made right ventricle to pulmonary artery (RV-PA) conduit for the Ross procedure, consisting of a fresh non-treated autologous pericardial (AP) patch for the posterior wall and expanded polytetrafluoroethylene (ePTFE) monocusp patch for the anterior wall. Long-term durability and RV function were assessed. Between 1997 and 2011, tailor-made conduits were used for right ventricular outflow tract (RVOT) reconstruction in 38 consecutive Ross procedures. Patients were divided into two groups by type of material used for reconstruction of the RVOT anterior wall: Group A (n = 11), pedicled AP patch with ePTFE monocusp valve; Group B (n = 27), ePTFE patch with the ePTFE monocusp valve. The posterior wall was reconstructed with an AP patch in both. We examined survival and freedom from re-intervention, haemodynamic indices by cardiac catheterization, efficacy of the RVOT by ultrasound cardiography (UCG) and exercise capacity at 3 years after the operation. The mean follow-up period was 6.0 ± 0.5 years. No patients required re-intervention for neo-aortic valve. Overall survival and freedom from re-intervention for RVOT reconstruction at 10 years were 100 and 100%, respectively, in Group A, and 92.6 and 89.4%, respectively, in Group B. No patients showed an RVOT pressure gradient greater than 25 mmHg by cardiac catheterization at 1 year after the operation. All showed less than 2.5 m/s of RVOT flow estimated by Doppler UCG at 6 years. RV function in both groups was preserved at normal in spite of a higher incidence of free RVOT insufficiency in Group A (P = 0.018). Exercise capacity was also preserved at normal in both groups. In paediatric patients undergoing the Ross procedure, a tailor-made conduit might be helpful to avoid growth-related RVOT obstruction. The incidence of free RVOT insufficiency was lower than with an anterior ePTFE patch, thus our method may be a better option to preserve RV function for a longer period.