Right ventricular outflow tract reconstruction with a polytetrafluoroethylene monocusp valve: A twelve-year experience

Abstract

Transannular patching of the right ventricular outflow tract results in pulmonary insufficiency. Biologic monocusp valves prevent early pulmonary insufficiency but usually become nonfunctional in less than 1 year. Polytetrafluoroethylene monocusp leaflets demonstrated favorable characteristics in our animal studies and have been applied to a variety of right ventricular outflow tract reconstructions at our institution. From 1994 through 2006, 192 patients (mean age, 3.3 +/- 5.0 years) underwent right ventricular outflow tract reconstruction with a polytetrafluoroethylene monocusp valve (192 patients; 202 implants). Intraoperative, early postoperative, and late follow-up echocardiographic data (mean interval, 4.9 +/- 3.1 years; range, 6 months to 12 years) were retrospectively obtained to compare clinical outcomes among three preoperative diagnostic groups: patients undergoing initial repair of tetralogy of Fallot or pulmonary atresia/ventricular septal defect (group I), patients undergoing redo right ventricular outflow tract procedures (group II), and patients undergoing complex initial repairs (group III). There were 4 early and 5 late deaths (9/192; 5%). The difference between the preoperative and postoperative peak right ventricular outflow tract gradients was significant (71.2 vs 23.1; P < .0001). Twenty-five (14%) patients had mild-to-moderate right ventricular outflow tract stenosis at one or more locations proximal and/or distal to the monocusp patch (mean gradient, 44.7 +/- 20.3 mm Hg). Freedom from increased pulmonary insufficiency greater than moderate was 86% at 1 year, 68% at 5 years, and 48% at 10 years. Twenty-five patients have undergone 35 reoperations 4.2 +/- 3.1 years (range, 3 months to 10 years after initial repair). Kaplan-Meier freedom from reoperation was 96%, 89%, and 82% at 1, 5, and 10 years. Freedom from reoperation in group II (69%) was significantly different from group I (88%; P = .01) and from group III (90%; P = .02), but there was no difference between groups I and III. Use of a polytetrafluoroethylene monocusp valve prevents early and significantly reduces midterm pulmonary insufficiency. It is relatively inexpensive, easy to construct, and remains free from significant stenosis in the majority of patients. We have not witnessed significant calcification or pulmonary embolization, and the only antithrombic agent used has been low-dose aspirin.