Outflow Tract Reconstruction In Children Research Articles

Medium-term outcomes of bovine jugular valved conduits for right ventricular outflow tract reconstruction in children: a retrospective cohort study from China

Medium-term outcomes of bovine jugular valved conduits for right ventricular outflow tract reconstruction in children: a retrospective cohort study from China

Decellularized bovine jugular vein and hand-sewn ePTFE valved conduit for right ventricular outflow tract reconstruction in children undergoing Ross procedure.

BackgroundThe Ross procedure is recommended as an optimal aortic valve replacement (AVR) in children and young adults due to several advantages. Nevertheless, multiple reconstructions of the right ventricular outflow tract (RVOT) with new valve conduits have caused some concern regarding the durability of the Ross AVR. Decellularized bovine jugular vein conduit (BJVC) (DP-BJVC) and hand-sewn expanded polytetrafluoroethylene valved conduits (ePTFE VC) are widely employed to reconstruct the RVOT with satisfactory long-term outcomes. However, few studies have compared the safety and efficacy between the two valve conduits. We aimed to evaluate the early outcomes and report our single center experience in the application of these conduits.MethodsTwenty-two pediatric patients (aged < 18 years) who underwent Ross procedures with DP-BJVC and ePTFE VC in our center between 1 June, 2017 and 31 January, 2022 were enrolled. The Kaplan–Meier method was used to evaluate survival, freedom from RVOT reintervention, and freedom from RVOT graft dysfunction. Mixed-effects analysis with the Geisser–Greenhouse correction and Sidak's multiple comparisons test for post-hoc analysis was employed to compare the peak gradient across the conduit at varying follow-ups.ResultsAll patients were followed up in full. The total early survival rate was 90.9%; two patients in the DP-BJVC group died. There was no significant difference in early mortality, cross-clamp time (p = 0.212), in-hospital stay (p = 0.469), and RVOT graft thrombosis or endocarditis between the two groups. There was similarly no significant difference between Kaplan–Meier freedom from RVOT graft dysfunction curve (P = 0.131). The transprosthetic gradient gradually increased over time in both groups and was significantly higher in the DP-BJVC group at follow-up (P < 0.05).ConclusionsBoth conduits show excellent early and midterm outcomes for RVOT reconstruction in the Ross procedure. We suggest that DP-BJVC is more suitable for infants, and ePTFE conduit is more suitable for older children who require larger conduits.

Ross Procedure in the era of Handmade-Valved Conduits for Right Ventricular Outflow Tract Reconstruction in Children: Short-Term Surgical Outcomes.

ObjectiveRoss procedure is considered as the “gold standard” for aortic valve replacement, but the conduits used for right ventricular outflow tract (RVOT) reconstruction, such as homografts and bovine jugular vein (BJV) conduits, are of limited availability in China. Handmade expanded polytetrafluoroethylene-valved conduits (HVCs) have been used recently as the alternative for RVOT reconstruction, but their specific experience in Ross procedure is limited in the literature.MethodsThis was a retrospective review of 27 children who underwent Ross procedure in our center from January 2018 to January 2022.ResultsMean age at surgery was 8.0 ± 3.8 years. During the study period, BJV conduits were used for RVOT reconstruction in 6 patients (22%), and HVCs were used in 21 patients (78%). Median conduit size was 20 mm (range, 16–24 mm), and mean conduit Z-score was +0.8 ± 0.9. Median time for cardiopulmonary bypass was 158 min (range, 109–275 min), and mean time for aortic crossclamping was 110 ± 21 min. There was no early mortality. During a median follow-up time of 1.4 years (range, 0.1–3.7 years), 3 patients (11%) with BJV conduits had peak conduit velocity of > 3.5 m/s; 3 patients (11%) with HVCs developed moderate conduit insufficiency; no patients had more than moderate conduit insufficiency. Three patients with BJV conduits had 5 reinterventions, and all received conduit replacement with HVCs.ConclusionHVC is an appealing alternative to BJV conduit for RVOT construction for children undergoing Ross procedure, with favorable short-term outcomes.

Right Ventricular Outflow Tract Reconstruction in Infant Truncus Arteriosus: A 37-year Experience

Multiple conduits for right ventricular outflow tract reconstruction exist, although the ideal conduit that maximizes outcomes remains controversial. We evaluated long-term outcomes and compared conduits for right ventricular outflow tract reconstruction in children with truncus arteriosus. Records of patients who underwent truncus arteriosus repair at our institution between 1981 and 2018 were retrospectively reviewed. Primary outcomes included survival and freedom from catheter reintervention or reoperation. Secondary analyses evaluated the effect of comorbidity, operation era, conduit type, and conduit size. One hundred patients met inclusion criteria. Median follow-up time was 15.6 years (interquartile range, 5.3-22.2). Actuarial survival at 30 days, 5 years, 10 years, and 15 years was 85%, 72%, 72%, and 68%, respectively. Early mortality was associated with concomitant interrupted aortic arch (hazard ratio, 5.4; 95% confidence interval, 1.7-17.4; P= .005). Median time to surgical reoperation was 4.6 years (interquartile range, 2.9-6.8; n=58). Right ventricle to pulmonary artery continuity was established with an aortic homograft (n= 14), pulmonary homograft (n= 41), or bovine jugular vein conduit (n= 36) in most cases. Multivariate analysis revealed longer freedom from reoperation with the bovine jugular vein conduit compared with the aortic homograft (hazard ratio, 3.1; 95% confidence interval, 1.3-7.7; P= .02) with no difference compared with the pulmonary homograft. Larger conduit size was associated with longer freedom from reoperation (hazard ratio, 0.7; 95% confidence interval, 0.6-0.9; P < .001). The bovine jugular vein conduit is a favorable conduit for right ventricular outflow tract reconstruction in patients with truncus arteriosus. Concomitant interrupted aortic arch is a risk factor for early mortality.

P3651Outcomes of right ventricular outflow tract reconstruction in children: comparison between bovine jugular vein graft and expanded polytetrafluoroethylene graft

Abstract Background Various types of conduits are available for right ventricular outflow tract reconstruction (RVOTR). The bovine jugular vein graft (BJVG) and expanded polytetrafluoroethylene graft (ePTFEG) have been descrived as an alternative to the homograft for RVOTR. Purpose- This study summarized the results to evaluate the single-center operation of RVOTR using BJVG and ePTFEG. Methods The valve functions of 27 patients under 20 years old who underwent primary RVOTR with BJVG and 26 patients with ePTFEG at our university hospital between 2013 and 2018 were retrospectively investigated. The valve conditions were assessed using echocardiography and cardiac catheterization. Results The median age at the time of operation was 1.8 years old (range, 6 days to 7.8 years old) with BJVG and 2.2 years old (range, 8 months to 9.1 years old) with ePTFEG. The median follow-up time was 3.4 years (range, 2 months to 5.2 years) with BJVG and 2.1 years (range, 1 month to 5.1 years) with ePTFEG. The peak RVOT gradient of BJVG was lower than ePTFEG (10.6±7.7 mmHg versus 18.1±16.2 mmHg, P=0.035). There were no differences in branch pulmonary stenosis defined as peak gradient up to 36mmHg (40.7% versus 50.0%, P=0.50) and pulmonary regurgitation graded worse than moderate (18.5% versus 11.5%, P=0.48) with BJVG and ePTFEG, respectively. Aneurysmal dilatation of the conduit was seen 22.2% with BJVG but none of patients with ePTFEG (P=0.01). All of patients with aneurysmal dilated BJVG had branch pulmonary stenosis. There were no differences in catheter intervention for branch pulmonary stenosis (22.2% versus 30.8%, P=0.48) and conduit replacement (11.1% versus 7.7%, log rank P=0.67) with BJVG and ePTFEG, respectively. There were no deaths during the fllow-up period in both groups. Conclusions The outcomes of RVOTR with BJVG and ePTFEG were clinically satisfactory. Aneurysmal dilatation was seen with BJVG and branch pulmonary stenosis was the risk factor for aneurysmal dilatation.

Downsized cryopreserved and standard-sized allografts for right ventricular outflow tract reconstruction in children: long-term single-institutional experience.

The objective of this study was to determine long-term results with bicuspidalized allografts compared to non-bicuspidalized allografts in children under 2 years undergoing primary correction of the right ventricular outflow tract. Thirty-five consecutive bicuspidalized allografts were compared to 45 consecutive non-bicuspidalized allografts implanted during the same period. Valve-related events were analysed with Kaplan-Meier and Cox-regression techniques. Mixed-effects modelling was used to analyse serial echocardiographic measurements of pulmonary gradient. In addition, a systematic review with meta-analysis of the published literature concerning implantation of bicuspidalized allografts was performed. Perioperative characteristics and in-hospital mortality [bicuspidalized 5 (14.3%), non-bicuspidalized 6 (13.3%)] were comparable (P = 0.902). Bicuspidalized allografts were smaller (14.7 vs 16.5 mm, P = 0.023) and always (100%) of pulmonary origin compared to 26 (57.8%) of the standard-sized allografts. There were no differences in late mortality between the bicuspidalized and non-bicuspidalized group (6.7% vs 7.7%, P = 0.798) or freedom from allograft replacement at 10 years (82 ± 10% and 71 ± 8%, for bicuspidalized and non-bicuspidalized allografts, respectively). Evolution of peak pulmonary gradient (P = 0.273) was comparable between bicuspidalized and non-bicuspidalized allografts. Meta-analysis showed a pooled early and late mortality for bicuspidalized allograft patients of 10.72% [95% confidence interval (CI) 6.13-18.75] and 1.6% per year (95% CI 0.99-2.79), respectively. Pooled estimated late reintervention and replacement rates were 5.94% per year (95% CI 3.42-10.30) and 3.78% per year (95% CI 2.69-5.32), respectively. Bicuspidalization seems to be a viable alternative to combat limited supply of small-sized allografts with acceptable survival and reintervention rates comparable to non-bicuspidalized allografts.

Polytetrafluoroethylene conduits versus homografts for right ventricular outflow tract reconstruction in infants and young children: An institutional experience

ObjectiveOur institution uses a valved polytetrafluoroethylene conduit as an alternative to homografts. The objective of this study was to investigate the performance of bicuspid valved polytetrafluoroethylene conduits used for right ventricular outflow tract reconstruction in children aged less than 2 years and to evaluate risk factors for earlier conduit explant. MethodsWe performed an Institutional Review Board–approved retrospective chart review of all patients aged less than 2 years who underwent surgical right ventricular outflow tract reconstruction with a bicuspid valved polytetrafluoroethylene conduit or homograft conduit from July 2004 to December 2014. The end points of the study were defined as conduit explant, conduit explant or reintervention, conduit stenosis, and conduit insufficiency. ResultsFifty-four patients underwent 65 right ventricular outflow tract reconstructions with a bicuspid valved polytetrafluoroethylene conduit (n = 39) or a homograft conduit (n = 26, 23 pulmonary, 3 aortic). The majority of diagnoses were truncus arteriosus (n = 28) and tetralogy of Fallot with pulmonary atresia (n = 19). Median age of patients at surgery was 134 (8-323) days and 128 (7-384) days in the PTFE and homograft groups, respectively. There was no difference in demographic data between the 2 groups. Time-to-event analysis demonstrated no difference in time to explant (P = .474) or time to explant or reintervention (P = .206) between the 2 conduit types. Younger age at surgery was the only independent risk factor for conduit explant (subdistribution hazard ratio 1.104 per 30 days younger, P < .001). There was no significant influence of conduit type on the development of moderate conduit stenosis (P = .931) or severe conduit insufficiency (P = .880). Larger conduit z score was protective for the development of moderate conduit stenosis (subdistribution hazard ratio, 0.46; P = .001). ConclusionsBicuspid valved polytetrafluoroethylene conduits are a satisfactory choice for right ventricular outflow tract reconstruction in patients aged less than 2 years. Their availability, low cost, and lack of potential sensitization make them an appealing alternative to homograft conduits.

Decellularized Allografts for Right Ventricular Outflow Tract Reconstruction in Children.

Determine the midterm outcomes of decellularized allografts for right ventricular outflow tract (RVOT) reconstruction in children less than 12 years of age. The study included all consecutive patients submitted to RVOT reconstruction with decellularized allografts between June 2006 and June 2016. Besides clinical and echocardiographic control, 20 patients with more than five years of follow-up were evaluated with computed tomography (CT) scans to determine allograft diameters and calcium scores. Structural valve deterioration was defined as any peak gradient above 40 mm Hg and/or insufficiency of moderate or severe degree. Conduit failure was defined as the need for allograft reintervention. There were 59 patients with a median age of six years (range = 0.01-12 years). The most common operation was the Ross procedure (34%). Mean clinical follow-up was 5.4 (2.8) years and was 94% complete. At eight years, only two patients needed a reintervention, with a 90.9% freedom from this event. Structural valve deterioration occurred in 13 patients, 5 due to stenosis and 8 due to insufficiency, with a freedom from structural valve deterioration due to any cause of 64.9% at eight years. Late CT scans demonstrated the absence or minimal calcification of the conduits. Decellularized allografts for RVOT reconstruction in children were associated with a low incidence of structural valve deterioration and conduit failure. Although these results still need to be confirmed in larger series and with longer follow-up, our data suggest favorable outcomes, at least in the first decade after the operation.

Pulmonary Valve Preservation Strategies for Tetralogy of Fallot Repair

was affirmed in a significant number of patients who tolerated the persistent effects of right ventricular volume overload for many years. In a significant number of postoperative patients, however, long-term complications of pulmonary regurgitation, residual ventricular septal defects (VSD), distal pulmonary artery stenosis, right ventricular dysfunction, atrial or ventricular arrhythmias, and exercise intolerance 2-5 required further operative intervention to address the residual defects, perform concomitant arrhythmia surgery, and pulmonary valve insertion.

Homografts and Xenografts for Right Ventricular Outflow Tract Reconstruction: Long-Term Results

Cryopreserved valved homografts are the most commonly used conduit for right ventricular outflow tract reconstruction in children. Early need for reoperation owing to accelerated fibrocalcification has been observed in neonates and children younger than 3 years. A valved bovine jugular vein conduit, Contegra, has shown good early results, without early accelerated fibrocalcification even in the very young patients. This study determined long-term results of homografts and midterm results of Contegra grafts, with special emphasis on reoperation rate. Between January 1993 and March 2009, 205 children received cryopreserved aortic homografts (n = 120, 66 blood group compatible [iso] and 54 non-blood group compatible [non-iso]) or Contegra grafts (n = 85, introduced in January 2000) for right ventricular outflow tract reconstruction and were followed from 6 months to 16 years. Primary diagnosis was tetralogy of Fallot (47%), pulmonary stenosis and atresia (19%), and truncus arteriosus (11%). Conduit dysfunction and need for reoperation were evaluated during follow-up. There were no hospital deaths in the homograft group and 2 deaths of conduit-unrelated cause in the Contegra group, During follow-up 3 patients died in the homograft group from graft-unrelated cause, and none died in the Contegra group. Early reoperation as a result of fibrocalcification and stenosis (within 2 years) was required in 1 Contegra graft patient (1.1%) compared with 8 patients in the homograft group (6.7%), all non-iso. Freedom from reoperation for Contegra grafts was 89.0% at 9 years, compared with non-iso homografts 63.0% and iso-homografts 85.7%. Non-blood group-compatible homografts have a significantly higher early reoperation rate than blood group-compatible homografts. Contegra grafts have a very low early reoperation rate and could therefore be used in neonates and children younger than 3 years of age, if a blood group-compatible homograft cannot be found. In children older than 3 years blood group compatibility is less important.

Pulmonary valve repair late after right ventricular outflow tract reconstruction in children and adolescents

Here, we report our experience with pulmonary valve (PV) repair using neoleaflet implantation in children and adolescents. Between April 2005 and May 2009, 20 patients underwent late PV repair with neoleaflet implantation for pulmonary regurgitation (PR) after reconstruction of the right ventricular outflow tract at <18 years of age. In patients with sufficient remaining native PV leaflets, the neoleaflet was implanted with a polytetrafluoroethylene membrane or fresh autologous pericardium to coapt with the remaining native PV leaflets. The median age at operation was 13 years (2-18 years). The median follow-up duration was 12 months (2-51 months). There was no early or late death. During follow-up, no significant PR was observed, but significant pulmonary stenosis (PS) developed in two patients who had a combined PS. The indexed right ventricular end diastolic dimension decreased during follow-up. At the latest follow-up, all patients were in New York Heart Association functional class I or II. PV repair with neoleaflet implantation can be performed safely and the outcome is satisfactory in the short-term, but attention must be paid in cases with combined PS. Longer follow-up should be carried out to investigate the changes in leaflet mobility and function, and pulmonary annular growth.

Mid-term results of the Contegra bovine jugular vein conduit for right ventricular outflow tract reconstruction in children

Mid-term results of the Contegra bovine jugular vein conduit for right ventricular outflow tract reconstruction in children

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.

Results with the freestyle porcine aortic root for right ventricular outflow tract reconstruction in children

Background The ideal choice for valved reconstruction of the right ventricular outflow tract (RVOT) in children is undetermined. This study explores the Freestyle porcine aortic root for these patients. Methods From January 1998 to December 2002, 56 patients ages 1.6 to 29.9 years old (mean 11.8 years old) underwent RVOT reconstruction using a Freestyle porcine aortic root. The patients averaged 1.9 prior operations (range 0 to 5) for tetralogy of Fallot ± pulmonary atresia (28 patients), critical pulmonary stenosis (10 patients), Ross procedure (5 patients), pulmonary atresia/intact ventricular septum (4 patients), complete atrioventricular septal defect ± tetralogy of Fallot (4 patients), and others (5 patients). At time of RVOT reconstruction, 42 patients (75%) had additional procedures including the following: tricuspid or mitral repair (24 patients), pulmonary arterioplasty ± Glenn (12 patients), ventricular septal defect closure (5 patients), aortic valve replacement (3 patients), placement of a cardioverter/defibrillator or pacemaker (3 patients), and others (8 patients). Results One patient developed mediastinitis; another was treated for Candida endocarditis (his excised homograft unexpectedly grew Candida). All patients are well on follow-up from 2 to 60 months (mean 30 ± 20 months) with no deaths. The patient with endocarditis underwent conduit replacement for recurrent pulmonary stenosis 3.5 years postoperatively. Echocardiography revealed mild or no pulmonary insufficiency in 93%. The calculated mean peak systolic RVOT gradient by echocardiography was 19.7 ± 15.4 mm Hg. Conclusions These data demonstrate excellent results with the Freestyle bioprosthesis for RVOT reconstruction in children. This valve may serve as a readily available alternative to homograft valves in RVOT reconstruction, particularly since early insufficiency seems to be less problematic. Questions of long-term durability and significance of echocardiographic stenosis remain unanswered.

Initial experience with a stentless porcine bioprosthesis for right ventricular outflow tract reconstruction in children

J Thorac Cardiovasc Surg 2003;125:727-8

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.

Pulmonary Root Replacement With the Freestyle Stentless Aortic Xenograft in Growing Pigs

Background. The stentless xenograft with its favorable hemodynamic performance on the left side of the heart seems an attractive, readily available alternative for the reconstruction of the right ventricular outflow tract in children. Methods. To assess its function in a preclinical animal investigation, we replaced the pulmonary root with a Freestyle stentless aortic xenograft in 18 piglets of 26.6 ± 3.2 kg weight. The animals were allowed to grow as much as possible and slaughtered when symptoms of heart failure developed or body weight reached more than 160 kg. All valve explants were analyzed by gross examination and photography and, in 4 representative pigs, by histologic examination. Results. Fourteen animals died prematurely after 2 weeks to 11 months. Twelve xenograft explants showed thick, immobilized, large nodular structures as cuspal remnants causing significant stenosis. At microscopy, large cuspal masses of degenerating collagen and fibrin and various inflammatory cells were frequently found. In the growing pig, most of the xenografts implanted in the pulmonary position showed early degeneration causing severe stenosis. Conclusions. Use of this valve for right ventricular outflow tract reconstruction in children cannot be recommended.