Bovine Jugular Vein Research Articles

Results with the contegra bovine jugular vein conduit for right ventricular outflow tract reconstruction in children

Objectives: Availability of homograft conduits, especially in small sizes is limited. The Contegra bovine jugular venous conduit may be a readily available alternative for right ventricular outflow tract (RVOT) reconstruction.

Mid term course after pediatric right ventricular outflow tract reconstruction: a comparison of homografts, porcine xenografts and Contegras

Homografts and porcine xenografts are valved conduits for pediatric RVOT reconstruction. They lack availability and durability. The Contegra, a glutaraldehyde fixed bovine jugular vein, was developed as an alternative. In this article, we compare single center results of 190 RVOT conduit implantations. 52 homografts, 30 porcine xenografts, 108 Contegras were implanted since 1992. Since 1999, data collection was prospective, for Contegras within a controlled clinical trial. Follow-up is complete for all evaluated items. We stratified reoperations by problem zone (sub-, intra-, and supravalvular) and analyzed the role of patient age, diagnosis, graft type, graft size, previous operations and year of operation on freedom from explantation or reoperation related to supravalvular reasons. Porcine xenografts were inferior concerning freedom from explantation and reoperation (P<0.0001). They gave erlier reason for explantation in each zone (P<0.001). At 4 years, homograft valve related reoperation need reached 20%, Contegras 0% (P=0.002). Supravalvlar reoperation reasons developed about equally in homografts and Contegras. Multivariable Cox' regression analysis showed porcine xenografts and age <1 year as independent risk factors for explantation due to supravalvular reasons. We found no reason to assume that supravalvular reoperation reasons occured more frequently after Contegra than after homograft implantation. After 12 years RVOT reconstruction with 190 valved conduits, Contegras remain our device of choice. At 4 years, they show no subvalvular or valvular reason for explantation or reoperation. Contegras have the advantages of easy handling and availability, and they compare well with homografts regarding freedom from explantation and freedom from reoperation.

The Contegra conduit in the right ventricular outflow tract induces supravalvular stenosis

ObjectiveWe sought to evaluate the incidence and nature of pulmonary stenosis after implantation of the bovine jugular vein graft (Contegra; Medtronic, Inc, Minneapolis, Minn) in the right ventricular outflow tract.MethodsBetween May 2000 and September 2002, 58 Contegra conduits (8-22 mm) were implanted during primary (n = 27) or redo operations (n = 31) in 57 patients, with ages ranging from 2 days to 48 years (mean, 9 years). Indications were truncus arteriosus (n = 16), tetralogy of Fallot (n = 28), pulmonary replacement in the Ross operation (n = 10), and Rastelli-type repair for double-outlet right ventricle (n = 4). Echocardiography was prospectively performed by a fixed team of investigators during follow-up (mean, 22.7 ± 10 months). A peak gradient of greater than 50 mm Hg was considered severe stenosis.ResultsTwo patients died from Staphylococcus aureus–induced septicemia and enterococcal endocarditis after 12 days and 12 weeks, respectively. One patient died of heart failure caused by endocardial fibroelastosis after 1 year. Freedom from severe stenosis at the distal anastomosis was 91% ± 3% at 3 months, 68% ± 6% at 12 months, and 49% ± 8% at 24 months. The risk of development of stenosis does not change over time. Younger age and its derivatives (graft size and indication) are significantly related to the occurrence of severe stenosis (P < .0001). Seventeen (29%) conduits required an endovascular intervention (balloon dilatation or stent). Seven (12%) conduits were explanted (endocarditis, 2; stenosis, 5). Histologic analysis of the explanted conduits showed excessive proliferation of neointima at the level of the distal anastomosis. Valve regurgitation was observed in 9 (16%) conduits and was always secondary to dilatation in the presence of severe distal stenosis.ConclusionThe Contegra conduit induces a neointimal proliferation at the level of the pulmonary anastomosis. This leads to a high incidence of severe stenosis at intermediate-term follow-up. We sought to evaluate the incidence and nature of pulmonary stenosis after implantation of the bovine jugular vein graft (Contegra; Medtronic, Inc, Minneapolis, Minn) in the right ventricular outflow tract. Between May 2000 and September 2002, 58 Contegra conduits (8-22 mm) were implanted during primary (n = 27) or redo operations (n = 31) in 57 patients, with ages ranging from 2 days to 48 years (mean, 9 years). Indications were truncus arteriosus (n = 16), tetralogy of Fallot (n = 28), pulmonary replacement in the Ross operation (n = 10), and Rastelli-type repair for double-outlet right ventricle (n = 4). Echocardiography was prospectively performed by a fixed team of investigators during follow-up (mean, 22.7 ± 10 months). A peak gradient of greater than 50 mm Hg was considered severe stenosis. Two patients died from Staphylococcus aureus–induced septicemia and enterococcal endocarditis after 12 days and 12 weeks, respectively. One patient died of heart failure caused by endocardial fibroelastosis after 1 year. Freedom from severe stenosis at the distal anastomosis was 91% ± 3% at 3 months, 68% ± 6% at 12 months, and 49% ± 8% at 24 months. The risk of development of stenosis does not change over time. Younger age and its derivatives (graft size and indication) are significantly related to the occurrence of severe stenosis (P < .0001). Seventeen (29%) conduits required an endovascular intervention (balloon dilatation or stent). Seven (12%) conduits were explanted (endocarditis, 2; stenosis, 5). Histologic analysis of the explanted conduits showed excessive proliferation of neointima at the level of the distal anastomosis. Valve regurgitation was observed in 9 (16%) conduits and was always secondary to dilatation in the presence of severe distal stenosis. The Contegra conduit induces a neointimal proliferation at the level of the pulmonary anastomosis. This leads to a high incidence of severe stenosis at intermediate-term follow-up.

Successful Primary Correction of Tetralogy of Fallot with Pulmonary Atresia and Aortopulmonary Window in a 2,220-g Neonate with a Valved Bovine Jugular Vein Conduit

Prenatal diagnosis of tetralogy of Fallot with pulmonary atresia (TOF/PA) was confirmed in a newborn with a birth weight of 2,095 g. Additionally, an aortopulmonary window (APW) type I was diagnosed on echocardiography. The operation was performed at the age of 4 weeks due to congestive heart failure. The APW was closed with a pericardial patch, the ventricular septal defect (VSD) with a Dacron patch, and the right ventricular outflow tract (RVOT) was reconstructed with a 12-mm bovine jugular vein valved conduit (Contegra, Medtronic Inc., Minneapolis, MN, USA). At 15-month follow-up, the patient is in excellent clinical condition without medication. On echocardiography, the conduit showed a mean gradient of 11 mmHg with first-degree insufficiency.

The Contegra conduit in the right ventricular outflow tract induces supravalvular stenosis

We sought to evaluate the incidence and nature of pulmonary stenosis after implantation of the bovine jugular vein graft (Contegra; Medtronic, Inc, Minneapolis, Minn) in the right ventricular outflow tract. Between May 2000 and September 2002, 58 Contegra conduits (8-22 mm) were implanted during primary (n = 27) or redo operations (n = 31) in 57 patients, with ages ranging from 2 days to 48 years (mean, 9 years). Indications were truncus arteriosus (n = 16), tetralogy of Fallot (n = 28), pulmonary replacement in the Ross operation (n = 10), and Rastelli-type repair for double-outlet right ventricle (n = 4). Echocardiography was prospectively performed by a fixed team of investigators during follow-up (mean, 22.7 +/- 10 months). A peak gradient of greater than 50 mm Hg was considered severe stenosis. Two patients died from Staphylococcus aureus -induced septicemia and enterococcal endocarditis after 12 days and 12 weeks, respectively. One patient died of heart failure caused by endocardial fibroelastosis after 1 year. Freedom from severe stenosis at the distal anastomosis was 91% +/- 3% at 3 months, 68% +/- 6% at 12 months, and 49% +/- 8% at 24 months. The risk of development of stenosis does not change over time. Younger age and its derivatives (graft size and indication) are significantly related to the occurrence of severe stenosis ( P < .0001). Seventeen (29%) conduits required an endovascular intervention (balloon dilatation or stent). Seven (12%) conduits were explanted (endocarditis, 2; stenosis, 5). Histologic analysis of the explanted conduits showed excessive proliferation of neointima at the level of the distal anastomosis. Valve regurgitation was observed in 9 (16%) conduits and was always secondary to dilatation in the presence of severe distal stenosis. The Contegra conduit induces a neointimal proliferation at the level of the pulmonary anastomosis. This leads to a high incidence of severe stenosis at intermediate-term follow-up.

Contegra pulmonary valved conduits cause no relevant hemolysis.

Contegra is a bovine jugular vein graft for pediatric RVOT reconstruction. Regular blood draws belong to a (controlled phase I) study protocol aiming at FDA-admission that included the first 60 patients. After 3.3 years we found not a single case of clinically relevant hemolysis and looked for reasons to eliminate this traumatic procedure from the protocol. Age of the patients ranged from 2 days to 17.4 years (median 1.6 years). Out of them 26 were males and 34 were females. Blood samples were taken before implant, before discharge, 1, 3, 6, and then every 6 months after implantation. Haptoglobin, free hemoglobin, reticulocytes, and hemoglobin were determined. We evaluate a total follow-up time of 132.6 years and 365 blood probes. We normalized the values to standard deviations, built a score (1 point for each value pointing toward hemolysis with at least two standard deviations) to compare divergent findings, and compared pre- and postoperative values. Finally, we analyzed the role of three patients with coexisting mechanical valve prostheses. High free hemoglobin was not associated with lower hemoglobin, indicating no chronic hemolysis. A high RVOT gradient as possible shear stress indicator was not associated with low haptoglobin or higher score values. All parameters turned into or toward normal ranges and showed less hemolysis than preoperatively. A mean of 1.1 parameters indicated (clinically irrelevant) hemolysis after 6 months or later. Haptoglobin was significantly lower in mechanical valve patients. There is no hint that Contegras cause hemolysis.

Right ventricular outflow tract reconstruction with the Contegra bovine jugular vein conduit: a word of caution

Background Since introduction in 1999, pulmonary valve replacement in pediatric patients with the Contegra conduit (Medtronic Inc, Minneapolis, MN) has gained widespread application with increasing enthusiasm. However, unexpected graft related adverse effects may occur. Methods Between April 2001 and December 2002, 29 patients (20 male; mean age, 3.39 ± 3.66 years; range, 0.01 to 13.0 years; mean weight, 11.62 ± 8.73 kg) underwent right ventricular outflow tract reconstruction with the Contegra conduit. Seventeen patients underwent primary repair, 8 had prior homografts, and 4 had other previous operations. Results There were no deaths. Three early graft related complications were observed. In two infants (age, 1.8 and 3.5 months; weight, 3.6 and 3.8 kg, respectively) thrombus formation at the conduit valve was detected 2 weeks postoperatively. Under anticoagulation with low-molecular-weight heparin, thrombi resolved completely in both patients. One patient (4.5 months, 4.43 kg) developed severe regurgitation due to a fibrous layer covering the inner conduit wall and required conduit exchange 3 weeks postoperatively. After a mean follow-up time of 10.2 ± 6.4 months all patients are in good clinical condition. However, one patient with systemic right ventricular pressure developed pseudoaneurysm at both graft insertion sites and is scheduled for reoperation. Two other patients underwent balloon dilation. Freedom from reoperation and intervention at 1 year is 89.4%. With regard to regurgitation and conduit stenosis all other conduits perform well. Conclusions Contegra conduits are an alternative to homografts for right ventricular outflow tract reconstruction. However, there is a risk of thrombus formation in small infants so that prophylactic anticoagulation may be necessary. Patients with systemic right ventricular pressure require close observation as pseudoaneurysm formation has been observed.

Contegra bovine jugular vein right ventricle to pulmonary artery conduit in Ross procedure

Background In the Ross procedure a valved conduit, most commonly pulmonary or aortic homograft, is used in place of autotransplanted pulmonary valve. Increasing demand and diminishing supply of homografts has resulted in a search for alternatives. A biological conduit from the valved segment of bovine jugular vein (Contegra) has been used successfully as an alternative. Methods Early clinical and echocardiographic results were analyzed retrospectively for 20 patients (median age 14.4 years) who underwent a Ross procedure with Contegra as right ventricle to pulmonary artery conduit between November and June 2003 (during the last 31 months). Results There was no operative mortality and late mortality or morbidity during the mean follow-up of 13.8 ± 9.1 months (range 1 to 31 months). No patient required reoperation. The median gradient at discharge was 16 ± 4.5 mm Hg, which remained unchanged at last follow-up. No deterioration in conduit or conduit valve function was noted. Conclusions This new bovine jugular vein conduit can be a viable alternative to a homograft in the Ross procedure. The early clinical and hemodynamic results are encouraging. Ease of availability and favorable handling and technical characteristics make it more attractive than a homograft. Xenograft origin of this conduit necessitates close follow-up for assessment of durability and longer-term results.

The bovine jugular vein conduit for right ventricular outflow tract reconstruction: a feasible alternative to homograft conduits?

J Thorac Cardiovasc Surg Angelini, Giovanni Stellin and Gino Gerosa Tomaso Bottio, Gaetano Thiene, Vladimiro Vida, Mila Della Barbera, Annalisa reconstruction: A feasible alternative to homograft conduits? The bovine jugular vein conduit for right ventricular outflow tract http://jtcs.ctsnetjournals.org/cgi/content/full/127/4/1204 located on the World Wide Web at: The online version of this article, along with updated information and services, is

Images in cardiovascular medicine. Percutaneous aortic valve replacement in animals.

In 2000, we percutaneously implanted a biological valve in the pulmonary artery of animals. A year later, we repeated the procedure in humans. Harvested from the bovine jugular vein, this valve was tested in vitro to assess its function when submitted to a diastolic pressure of 100 mm Hg, as well as its durability. The valve is shown in the closed and opened positions …

Adverse mid-term outcome following RVOT reconstruction using a valved bovine jugular vein

Adverse mid-term outcome following RVOT reconstruction using a valved bovine jugular vein

Formation of a stenotic fibrotic membrane at the distal anastomosis of bovine jugular vein grafts (Contegra) after right ventricular outflow tract reconstruction

dental’ endoesophageal intubation or prompt surgical tracheostomy (Floyd type I). Surgical repair or palliation of associated congenital cardiac lesions has been never described in the literature, because most affected patients usually die before any attempt at surgical intervention. This is the first patient to our knowledge to survive palliation of the respiratory tract malformation as well as definitive intracardiac repair. She is now thriving and is currently being evaluated for definitive surgical reconstruction of the airway and alimentary tract. References

Bovine valved xenograft conduits in the extracardiac Fontan procedure

Total cavopulmonary connection has been proposed as a rational alternative to atriopulmonary connection for complex Fontan operations. de Leval and colleagues proposed the concept of direct cavopulmonary connection as a way to minimize kinetic energy loss in the Fontan circuit. Total cavopulmonary anastomosis with the extracardiac conduit technique has gained favor because it streamlines the venous flow pattern and reduces the incidence of atrial arrhythmias. There are a number of potential advantages of the extracardiac conduit approach over other modifications of the Fontan procedure, including the improved hydrodynamics in the cavopulmonary connection. Conduits of different material have been used for the extracardiac Fontan procedure, examples of these conduits are the Dacron tube, the polytetrafluoroethylene tube (Gore-Tex; W. L. Gore & Associates, Inc, Flagstaff, Ariz), the homograft, and the pericardial tube, and each one has advantages and disadvantages. Bovine jugular vein xenograft (Medtronic’s Contegra, Medtronic, Inc, Minneapolis, Minn) has been used successfully to reconstruct the right ventricular outflow tract in patients with congenital heart disease, with promising early results. The Contegra conduit is a biologic valved conduit consisting of a glutaraldehyde-preserved heterologous bovine jugular vein with a trileaflet venous valve. The advantages of using the Contegra xenograft are easy availability, different size options, and the presence of a valve in the conduit. In this report we present potential advantages of using a xenograft valved conduit to construct the extracardiac Fontan connection between the inferior vena cava (IVC) and the pulmonary artery (PA).

Use of bovine jugular vein to reconstruct the right ventricular outflow tract: early results

Objective We evaluate early results of bovine jugular vein conduits in the pulmonary outflow. Methods Between April 2000 and September 2001, 31 conduits were placed in the outflow of the right ventricle. Patients who received a conduit as a staged surgical procedure were excluded (n = 3). Implantation age ranged from 0 to 21 years (median, 3.4 years). Conduit diameter ranged from 12 to 20 mm (median, 14 mm). Transthoracic echocardiography was performed at discharge and 3 months after surgery. Patients with significant pulmonary regurgitation and/or stenosis underwent cardiac catheterization. Results Four patients died during the follow-up period. Three deaths were unrelated to the conduit. One death was related to the complete thrombosis of the conduit. At 3 months evaluation, pulmonary valve regurgitation was absent or trivial in 19, mild in 2 and severe in 3 of 24 survivors. Four patients had nonfatal conduit-related complications. A transient thrombus formation within 1 leaflet was noted postoperatively in a patient with a moderate pulmonary regurgitation. Three patients required reoperation 3 to 5.8 months after the implantation for conduit failure (mean, 4.3 months). Cardiac catheterization before replacement revealed an aneurysmal dilation of the conduit below a severe stenosis of the pulmonary bifurcation due to important neointimal proliferation. Conclusions Early failure of bovine jugular vein valved conduits can occur because of exaggerated intimal proliferation or thrombotic process within the conduit. Because of these complications, close echocardiographic follow-up is mandatory during the first weeks after implantation.

Early results of using the bovine jugular vein for right ventricular outflow reconstruction during the Ross procedure.

To study the early function of the bovine jugular vein (BJV) when used for right ventricular outflow tract (RVOT) reconstruction during the Ross procedure. Seventeen consecutive patients (median age, 12 years; range, 30 days to 40 years) who had undergone a Ross procedure with RVOT reconstruction using a BJV were reviewed. Nine patients had prior balloon valvotomy (n = 6) and/or surgical aortic valvotomy (n = 4). Additional procedures included a reduction-plasty of the ascending aorta (5 patients), a Konno procedure (2 patients), a mitral valve repair/replacement (2 patients), and others (3 patients). The size of the BJV ranged from 12 to 22 mm (median, 20 mm). There were no early or late deaths. None of the patients encountered any significant postoperative complications. The neo-aortic valve showed good function in all patients with no more than trivial insufficiency. At a median follow-up period of 11 months, the frequency of freedom from BJV graft dysfunction/reintervention/reoperation was 100%. One patient had moderate insufficiency of the BJV in a perioperative examination that regressed to mild insufficiency during follow-up. Overall, none of the patients had more than mild insufficiency at follow-up. Four patients showed a flow acceleration of more than 250 cm/s (equivalent to a gradient of 25 mm Hg) across the BJV, and the remaining patients had lower gradients. The BJV, when used to replace the pulmonary valve in the Ross procedure, showed excellent function in the early phase. The large size range and easy availability of this valved conduit are particularly attractive. Further followup is needed to determine the long-term results of its use.

Bovine jugular vein thrombosis in the Fontan circulation

J Thorac Cardiovasc Surg 2002;124:1038-40

Increase in apoptotic polymorphonuclear neutrophils in peripheral blood after intramammary infusion of Escherichia coli lipopolysaccharide

A transient increase in apoptotic polymorphonuclear neutrophils (PMNs) as revealed by the terminal deoxynucleotidyl, transferase-mediated dUTP nick end labeling (TUNEL) technique in bovine jugular and milk vein blood was observed 4 h after intramammary infusion of Escherichia coli lipopolysaccharide (LPS) (jugular vein; before infusion 10.1%, 4 h 58.3%: milk vein; before infusion 13.2%, 4 h 76.6%) decrease in PMA-induced oxidative bursts of PMNs was also observed during the same period and continued until 8 h after the infusion. TUNEL-positive cells showed an intention of a Comet tail as detected by a single-cell gel electrophoresis assay (Comet assay) and the morphological apoptotic future, though DNA fragmentation was not clearly detected. A definite decrease in peripheral PMNs and a marked increase in PMNs in the LPS-infused teat cistern were observed during the same period. The migration of milk vein blood-derived PMN and the expression of adhesion receptors (L-selectin and CD18) on PMN were suppressed, accompanied by an increase in apoptotic cells. TUNEL-positive PMN observed in normal animals showed a reduced migration capacity. The increase in apoptotic PMNs observed in the LPS-infused cattle was thought to be due to the remaining intravenous spontaneous apoptotic cells existing under the normal condition (the aging cell), and this increase appeared to lower the expression of adhesion receptors and the migration capacity. Decreased PMA-induced oxidative burst activity in PMN was thought to be derived from these aging cells and immature band cells appearing in the circulation as a subsequent event of leukopenia and/or severe stress associated with mastitis. The results from the present study indicate the possibility that the function of PMN in the circulation at early stages of bovine mastitis is regulated by the kinetics of PMN aging.

Valved jugular vein segments for right ventricular outflow tract reconstruction in young sheep

Objective: This study was undertaken to investigate the degeneration and calcification of valved bovine jugular vein segments for right ventricular outflow tract reconstruction in juvenile sheep. Methods: Seven valved bovine jugular vein conduits (Contegra model 220; VenPro Corporation, Irvine, Calif) and 3 control conduits (MH100; Medtronic, Inc, Minneapolis, Minn) were implanted in the pulmonary artery in young sheep. After 20 weeks the conduits were explanted and qualitatively analyzed by epicardial echocardiography, gross examination, x-ray analysis, light microscopy, and transmission electron microscopy. Calcification was determined quantitatively by flame atomic absorption spectrometry. Results: Two Contegra conduits could not be analyzed because of endocarditis. All other Contegra conduits functioned well, with preserved structure and minimal calcification. The control MH100 conduits exhibited extensive fibrous sheathing, with calcification of the aortic wall portion and the commissural part of the Hancock valve. Conclusions: The Contegra conduit's performance was clearly superior to that of the control MH100 conduit when implanted in the pulmonary artery position in juvenile sheep for 5 months.J Thorac Cardiovasc Surg 2002;124:798-805

Early results of valved bovine jugular vein conduit versus bicuspid homograft for right ventricular outflow tract reconstruction

Background. Homograft conduits are preferable for right ventricular outflow tract reconstruction in children, but their limited availability remains a major concern. Recently, a valve-containing segment of bovine jugular vein (Contegra, Medtronic Inc, Minneapolis, MN) has been introduced as a potential alternative conduit. Methods. Early clinical and echocardiographic results of right ventricular outflow tract reconstruction were retrospectively compared between 41 children (mean age, 1.9 years), receiving a Contegra conduit and 36 patients (mean age, 2.7 years) with a size-reduced pulmonary homograft. Results. Clinical outcome was comparable with two early deaths in the homograft group and one in the Contegra group. There were no conduit-related complications in either population. Early echocardiographic assessment showed only trivial to mild regurgitation in 9 homografts versus 17 Contegra conduits. The peak gradient across the right ventricular outflow tract conduit was comparable for both groups, although a larger number of patients, treated with a downsized homograft, had a small gradient at the distal junction with the pulmonary arteries (12 versus 6 patients). None of the patients had a gradient at the valvar level. Conclusions. The valved bovine jugular vein conduit offers a promising substitute for right ventricular outflow tract reconstruction in infants and children, with an early hemodynamic performance that compares favorably with downsized, bicuspid homografts. Clinical advantages are greater shelf availability and the natural continuity between valve and conduit, which allows proximal infundibular shaping without additional material. However, durability must be determined, even though most of these children will require right ventricular outflow tract reoperation after outgrowing the conduit.

Percutaneous implantation of a valve in the descending aorta in lambs.

We assessed the feasibility of percutaneous implantation of a valve in the descending aorta and its function in systemic pressures. A biological valve harvested from a bovine jugular vein was sutured into a stent. After the creation of aortic insufficiency, the valved stent was percutaneously implanted into eight lambs divided into two groups depending on the severity of the insufficiency created. Haemodynamic and angiographic evaluations were carried out. Anatomical evaluation was finally performed. Aortic insufficiency was created: four lambs had mild insufficiency and four massive insufficiency. A valve was successfully implanted in all and were functioning perfectly in the early follow-up. Despite this competence, animals with massive insufficiency died within 24 h following implantation. None of the animals with mild insufficiency died. The valve was functioning perfectly in the first 2 months following the implantation, but became incompetent after spontaneous healing of the wound of the aortic valve. Percutaneously implanted valves in the descending aorta of lambs with aortic insufficiency function well in the early follow-up. This technique might become an interesting alternative to the standard approach in patients in whom perioperative risk is high.