Pulmonary Homograft Research Articles

Arrow Shaped Ministernotomy Approach for the Ross Procedure

Objective: The Ross procedure is thought to have the best long-term results among aortic valve surgical interventions and has excellent hemodynamic characteristics and very low risk of valve thrombosis. We report the first four cases of arrow shaped ministernotomy Ross procedures in young adult patients. Methods: One female and three young male patients aged 42, 33, 43 and 44 respectively, with congenital complete Type 1 A bicuspid aortic valve disease received a Ross procedure via a ministernotomy approach. After a 6-7 cm skin incision, the sternum was divided in the shape of an arrow, down to the third intercostal space. The cardiopulmonary bypass was established through central cannulation. The pulmonary autograft was prepared before aortic cross-clamp and implanted in the aortic position with the everted miniroot technique. This was followed by the pulmonary homograft implantation in the pulmonary position. The arrow shaped sternotomy was closed with a technique developed by us, using an “X” sternal wire at the level of the transversal sternotomy, which was further stabilized with a “butterfly” configuration between the “X” wire and the next proximal standard wire. Results: The cardiopulmonary bypass and aortic cross clamp time were between 144-148 and 84-87 minutes respectively. The intervention was uneventful, with very good intraoperative transoesophagial echocardiography results. The postoperative course was straightforward (1 day in ITU, 7 days in-hospital stay). The 3-month follow-up results were excellent regarding both the echocardiographic and cosmetic results. Conclusions: The arrow shaped ministernotomy offers the advantage of a wider, more comfortable approach for both the aortic and pulmonary conduits, making it safer for minimally invasive Ross procedures, compared to the partial “J” sternotomy approach.

Narrative review of the contemporary surgical treatment of unicuspid aortic valve disease.

Unicuspid aortic valve disease (UAVD) is a frequent and long-lasting challenge for adult congenital heart disease centers. UAVD patients become usually symptomatic in their twenties or thirties and require a surgical treatment plan which should respect their complete lifespan combined with an adequate quality of life. Unfortunately, all current surgical strategies of congenital aortic valve disease bear some important limitations: (I) Aortic valve replacement using bioprosthetic valves is associated with early structural degeneration and leads frequently to re-operations. (II) Mechanical valves are commonly associated with lifelong risk of severe bleeding due to oral anticoagulation. (III) Using a pulmonary autograft (i.e., Ross procedure) for aortic valve replacement is associated with excellent long-term results in non-elderly patients. However, failure of pulmonary autograft or pulmonary homograft may require re-operations. (IV) Aortic valve repair or Ozaki procedure is only performed in a few heart centers worldwide and is associated with a limited reproducibility and early patch degeneration, suture dehiscence or increased risk of endocarditis. In contrast to degenerative tricuspid aortic valve disease, UAVD remains relatively understudied and reports on UAVD treatment are rare and usually limited to retrospective single-center observations. For this review, we searched PubMed for papers in the English language by using the search words unicuspid aortic valve, congenital aortic valve, Ross procedure, Ozaki procedure, aortic valve repair, mechanical/bioprosthetic aortic replacement, homograft. We read the abstracts of relevant titles to confirm their relevance, and the full papers were then extracted. References from extracted papers were checked for additional relevant reports. This review summarizes current surgical treatment strategies for UAVD including aortic valve replacement using bioprosthetic or mechanical valves, homografts, pulmonary autografts (i.e., Ross procedure) and aortic valve repair techniques for UAV. Furthermore, Ozaki procedure will be discussed.

Long-term outcomes of right ventricle-to-pulmonary artery conduit insertion in adults with congenital heart disease: survival analysis by National Death Index.

The aim of this study was to investigate the long-term outcomes following right ventricle-to-pulmonary artery (RV-to-PA) conduit insertion of Medtronic Freestyle® porcine valve (MFV) or pulmonary allograft valve (PAV) in adult patients with congenital heart disease. Retrospective medical record review of consecutive RV-to-PA conduit insertion, using either PAV or MFV from 1991 to 2017. Perioperative data and clinic reports were collected. Cause and date of death were obtained from the Australian National Death Index to obtain survival function. In total, 232 patients (median age 31.5 years, interquartile range 25-41 years) underwent RV-to-PA conduit insertion (PAV = 84 and MFV = 148) and were eligible for inclusion [63.8% tetralogy of Fallot (TOF); 11.6% congenital pulmonary stenosis (PS); 24.6% other diagnoses]. The overall median follow-up time was 9.1 years (interquartile range 5.3-12.6 years). The mean gradient was 11.8 ± 7.1 mmHg in PAV and 16.6 ± 9.6 mmHg in MFV patients. Congenital PS patients had 100% survival at 20 years, TOF patients at 5, 10, 15 and 20 years had 99%, 97%, 96% and 96% survival, respectively. Patients with other primary diagnoses at 5, 10, 15 and 20 years had 93%, 91%, 87% and 87% respectively. Freedom from reintervention did not differ significantly at 5 and 10 years between pulmonary allograft (98.6%, 98.6%) and Freestyle® porcine bioprosthesis (97.5%, 93%). Both valves perform equally well with regard to patients' freedom from reoperation, although transvalvular gradient was higher for Freestyle® patients. Congenital PS and TOF patients had better survival than patients with other primary diagnoses.

The Pulmonary Microbiome after Lung Transplantation is Associated with Gastroesophageal Reflux Disease, Inflammation, and Allograft Dysfunction

<h3>Purpose</h3> The pulmonary microbiome modulates the immune milieu in the lung allograft and is in turn influenced by gastroesophageal reflux disease (GERD). Although GERD has been linked to a higher risk of chronic lung allograft dysfunction (CLAD), the underlying role of the allograft microbiome is unknown. We assessed the relationships between the post-transplant pulmonary microbiome, GERD, inflammation, and allograft dysfunction. <h3>Methods</h3> 24 GERD and 51 no-GERD patients, defined by pH-impedance probe, had bronchoalveolar lavage (BAL) obtained at 3, 6, 9, and 12 months post-transplant. A separate cohort of 18 patients who underwent Nissen fundoplication for GERD within the first year post-transplant had BAL obtained before and after surgery. BAL were analysed for microbial communities and inflammatory cytokines using 16S rRNA sequencing and immunoassays, respectively. <h3>Results</h3> Hierarchical clustering of all GERD and no-GERD samples by Bray-Curtis dissimilarity identified three distinct community state types (CST) (Figure A). CST1 was positively associated with GERD and enriched in <i>Prevotella</i> and <i>Veillonella</i>. CST2 was negatively associated with GERD and enriched in <i>Streptococcus</i>. CST3 was independent of GERD and enriched in <i>Pseudomonas</i> and <i>Staphylococcus</i>. Compared to other CSTs, CST3 was associated with a greater proportion of patients with BAL inflammation, concurrent acute decline in lung function at 3 months, and earlier CLAD onset. Patients with the greatest decrease in BAL inflammation post-Nissen also had decreases in bacterial load and density of <i>Prevotella</i> (Figure B). <h3>Conclusion</h3> Pulmonary microbiota after lung transplantation cluster into three CSTs which differ by their associations with GERD. CST3 may represent a GERD-independent state of microbial dysbiosis which promotes inflammation and allograft rejection. Anti-GERD surgery appears to decrease GERD-associated microbiota.

Long-term Clinical and Echocardiographic Outcomes in Young and Middle-aged Adults Undergoing the Ross Procedure

There is no ideal valve substitute for young adults requiring aortic valve replacement. Multicenter data supporting use of the Ross procedure with respect to long-term postoperative valve-related mortality and reintervention, as well as function of the autograft and pulmonary homograft, are needed. To determine the long-term clinical and echocardiographic outcomes in young and middle-aged patients undergoing the Ross procedure. A retrospective multicenter international cohort study with a median follow-up period of 9.2 years was conducted in 5 experienced centers regularly performing the Ross procedure. Consecutive patients aged 18 to 65 years were included by each center between 1991 and 2018. Survival and autograft-related and homograft-related reintervention. Serial echocardiographic measurements of valve function were analyzed using mixed-effects modeling. During the study period, 1431 patients (74.3% men; n = 1063) were operated on at a median age of 48.5 years (mean [SD], 47.7 [9.5]; range, 18.1-65; interquartile range, 42.7-54.0). Implantation techniques were root inclusion in 355 (24.9%), root replacement in 485 (34.0%), and subcoronary implantation in 587 (41.1%). Right ventricular outflow tract reconstruction was performed with homografts in 98.6% (n = 1189) and bioprostheses in 1.4% (n = 17). Ten patients (0.7%) died before discharge. Median follow-up was 9.2 years (13 015 total patient-years). Survival after 10 and 15 years was 95.1% (95% CI, 93.8%-96.5%) and 88.5% (95% CI, 85.9%-91.1%), respectively. Freedom from autograft and homograft reintervention after 15 years was 92.0% and 97.2%, respectively. Late events were autograft endocarditis in 14 patients (0.11% per patient-year), homograft endocarditis in 11 patients (0.08% per patient-year), and stroke in 37 patients (0.3% per patient-year). Given its excellent short-term and long-term outcome in young and middle-aged adults in this study, the Ross procedure should be considered in young and middle-aged adults who require aortic valve replacement. Patients should be referred to an experienced center with a program dedicated to the Ross procedure.

Oversize It: Valuable Advice for Larger Right Ventricle-to-Pulmonary Artery Conduits

Longevity of Large Aortic Allograft Conduits in Tetralogy With Major Aortopulmonary CollateralsThe Annals of Thoracic SurgeryPreviewAppropriate conduit selection for right ventricle (RV)-to-pulmonary artery (PA) connection has been extensively studied, with older implantation age, pulmonary (vs aortic) homografts, and true sizing associated with increased longevity. Notably, patients with PA arborization abnormalities (ie, major aortopulmonary collateral arteries [MAPCAs]) are reported to require earlier and more frequent conduit interventions. We aim to understand the behavior of large-diameter aortic homografts in patients with MAPCAs, which are programmatically utilized at our institution. Full-Text PDF

Outcomes Following Heterotopic Placement of Right Ventricle to Pulmonary Artery Conduits

We sought to evaluate the outcomes following right ventricle to pulmonary artery (RV-PA) conduit placement in pediatric patients, excluding those with a RV-PA conduit for the Ross procedure which is associated with improved conduit durability, partly related to its orthotopic position. Outcomes for 119 patients who underwent RV-PA conduit placement at a single institution from January 2004 to December 2016 were reviewed. Primary outcome measures were reintervention-free survival (RFS) and overall survival. Survival analyses were performed using the Kaplan-Meier method, and risk factors associated with reintervention were evaluated. The median age at the time of conduit placement was 6 months (interquartile range, IQR: 1-14), and the median length of follow-up was 63 months (range: 0-156). During follow-up, 39 patients required conduit-related reintervention, while 6 patients died perioperatively with an overall survival of 90% at 10 years. Among the remaining 113 patients, the RFS at one, five, and ten years was 91% (84%-95%), 72% (60%-80%), and 33% (16%-50%), respectively. The median time to conduit replacement in the series was 43.5 months (IQR: 19.3-76.2). The use of a pulmonary homograft was associated with improved RFS (P = .03), and this was particularly pronounced in comparison with aortic homografts in neonates. Infection was the indication for replacement in only one patient. The majority of the conduits placed during the neonatal period required conduit replacement before the age of five years. Endocarditis was not a common indication for replacement. In neonates and infants, we prefer pulmonary homografts for most indications.

Scalloped Freehand Pulmonary Homograft for Prosthetic Tricuspid Valve Replacement

Tricuspid valve replacement is commonly performed using biologic or mechanical prostheses. Partial or complete valve replacement using mitral homograft tissue has also been described. Anecdotal reports exist of valve replacement using a pulmonary homograft within a cylinder. This report describes a technique for native or prosthetic valve replacement using a freehand scalloped pulmonary homograft. Late follow-up confirmed the efficacy of this surgical strategy.

Surgical therapy of infective endocarditis following interventional or surgical pulmonary valve replacement.

Percutaneous pulmonary valve prostheses and right ventricle-to-pulmonary artery conduits are at risk for infective endocarditis (IE). In children and adults with a congenital heart disease, a pulmonary valve implant is frequently necessary. Prosthetic valve endocarditis is a conservatively barely manageable, serious life-threatening condition. We investigated the results of surgical pulmonary valve replacements in patients with IE. A total of 20 patients with congenital heart disease with the definite diagnosis of IE between March 2013 and July 2020 were included in this single institutional, retrospective review. Infected conduits were 11 Melody, 5 Contegra, 3 homografts and 1 Matrix P Plus. All of the infected prosthetic material was removed from the right ventricular outflow tract up to the pulmonary bifurcation. Pulmonary homografts were implanted after pulmonary root resection as right ventricle-to-pulmonary artery conduits. All patients survived and were discharged infection-free. The mean time from the conduit implant to the operation for IE was 4.9 years [95% confidence interval (CI), 3.0-6.9]. The median intensive care unit stay was 3.0 days (95% CI, 2.0-4.7), and the median hospital time was 25.0 days (95% CI, 19.2-42.0). Median follow-up time was 204.5 days (range 30 days to 5 years) without death or recurrent endocarditis. The surgical treatment of IE of percutaneous pulmonary valve prostheses and right ventricle-to-pulmonary artery conduits is a safe and effective therapeutic concept. Early surgical referral of patients with suspicion of IE should be pursued to avoid sequelae such as right ventricular failure, septic emboli, intracardiac expansion and antibiotic resistance.

Longevity of Large Aortic Allograft Conduits in Tetralogy With Major Aortopulmonary Collaterals

BackgroundAppropriate conduit selection for right ventricle (RV)-to-pulmonary artery (PA) connection has been extensively studied, with older implantation age, pulmonary (vs aortic) homografts, and true sizing associated with increased longevity. Notably, patients with PA arborization abnormalities (ie, major aortopulmonary collateral arteries [MAPCAs]) are reported to require earlier and more frequent conduit interventions. We aim to understand the behavior of large-diameter aortic homografts in patients with MAPCAs, which are programmatically utilized at our institution. MethodsThis is a single-center retrospective cohort study including all children less than 12 years of age who underwent RV-PA connection using an aortic homograft greater than or equal to 16 mm diameter between 2002 and 2019, with a primary outcome of freedom from any RV-PA reintervention and a secondary outcome of freedom from surgical reintervention. Patients were grouped by absolute and indexed conduit sizes for further analysis. ResultsA total of 336 conduits were followed for a median of 3.0 years; transcatheter (n = 30) or surgical (n = 35) reintervention was performed on 64 conduits. Estimated freedom from reintervention and surgical replacement was 84% and 90% at 5 years. Younger age and smaller absolute conduit size were associated with earlier reintervention, but conduit Z-score (median 3.5) was not associated with outcome. ConclusionsThe programmatic use of oversized aortic homograft RV-PA conduits in the surgical repair of MAPCAs provides a focused experience that demonstrates similar longevity to reported best alternatives. Secondarily, conduit oversizing may improve durability and enables an increased likelihood of nonoperative reintervention.

Inverted aortic bioprosthetic for mitral valve replacement with Ross procedure: case report

BackgroundA 34-year-old gentleman presented with Staphylococcus salivarius infective endocarditis 13 years after aortic homograft and mitral valve repair for degenerative bicuspid aortic valve associated with rheumatic heart disease. The homograft had calcified, and the mitral repair had deteriorated with severe regurgitation. Multidisciplinary team decision to restore best quality of life was for re-do Ross procedure with bi-leaflet preserving mitral valve replacement with an inverted RESILIA aortic valve as the patient was fundamentally against lifelong anti-coagulation.Case presentationThe aortic homograft was excised, and coronary arteries dissected out followed by harvesting of the pulmonary autograft. The mitral valve was accessed via a trans-septal approach. On examination, there was a restricted and thickened posterior mitral valve leaflet. An inverted 27-mm INSPIRIS RESILIA aortic bio-prosthesis was placed with mitral cusps preserved. The pulmonary autograft was implanted in an intra-annular position, and a 26-mm pulmonary homograft was used to replace the pulmonary valve. Echocardiogram at 4 weeks revealed preserved LV function and well-functioning prosthetic, autograft and homograft.ConclusionAn inverted RESILIA valve, with its anti-structural valve deterioration properties, can be used in the mitral position with preservation of the mitral cusps to avoid anti-coagulation with the hope of reducing need for re-operation in line with patient wishes.

An In Vitro Model to Study Endothelialization of Cardiac Graft Tissues Under Flow.

Pulmonary valve replacement is performed with excellent resultant hemodynamics in patients that have underlying congenital or acquired heart valve defects. Despite recent advancements in right ventricular outflow tract reconstruction, an increased risk of developing infective endocarditis remains, which has a more common occurrence for conduits of bovine jugular vein (BJV) origin compared with cryopreserved homografts. The reason for this is unclear although it is hypothesized to be associated with an aberrant phenotypic state of cells that reendothelialize the graft tissue postimplantation. The aim of this study was to develop an in vitro model that enables the analysis of endothelial cell (EC) attachment to cardiac graft tissues under flow. In the experiments, EC attachment was optimized on bovine pericardium (BP) patch using human umbilical vein ECs. Different biological coatings, namely gelatin, fibronectin, plasma, or a combination of fibronectin and plasma were tested. After cell adaptation, graft tissues were exposed to laminar flow in a parallel-plate flow chamber. Cell retention to the tissue was analyzed after nuclear staining with YO-PRO-1 and a membranous localization of VE-cadherin. Experiments showed that combined coating with fibronectin and blood plasma together with a two-phased shear pattern resulted in a relevant cell monolayer on BP patch and cryopreserved homograft. For BJV tissue, no adherent cells under both static and shear conditions were initially observed. In conclusion, having established the new flow chamber system we could obtain EC layers on the surface of BP patch and cryopreserved pulmonary homograft tissues. The presented in vitro system can serve as a competent model to study cell phenotypes on cardiac grafts in the close-to-physiologic environment. Moreover, this approach allows broad applications and enables further development by testing more complex conditions.

Staged repair of truncus arteriosus with double aortic arch, tracheoesophageal fistula, and choanal atresia via a multi-disciplinary approach: a case report

The previously unreported case of a child with an exceedingly rare amalgamation of complex defects, including truncus arteriosus (TA), double aortic arch (DAA), tracheoesophageal fistula, and choanal atresia is presented. First, on day-of-life (DOL) 2, with a joint effort involving Pediatric Cardiac Surgery, General Surgery, and Otolaryngology, division of tracheoesophageal fistula and repair of esophageal atresia, along with choanal atresia repair, was carried out. Via a right thoracotomy, the tracheoesophageal fistula, located medial to the azygous vein, was skeletonized and ligated. The proximal esophagus was then mobilized up to the thoracic inlet as it coursed through the vascular ring. This enabled esophageal anastomosis with preservation of both aortas. Next, on DOL 11, the child underwent TA repair. Following a standard midline sternotomy and cooling to moderate hypothermia, the left aortic arch was divided and oversewn. The aorta was then transected anteriorly, and the main pulmonary artery (MPA) exiting the posterior aorta was harvested as a single button. The aortic defect from the pulmonary artery button was repaired with autologous pericardium. Next, through a right ventriculotomy, the previously seen conoventricular septal defect was identified and closed. Finally, a 10-mm pulmonary homograft was anastomosed to the pulmonary artery bifurcation to complete the repair. The patient was discharged on DOL 78 and was noted to be doing well at 1-year follow-up. This case validates the feasibility of fistula repair complicated by DAA through a right thoracotomy, the durability of staged, complete repair of TA and DAA, and the advantages of a holistic, team-based approach that optimizes timing of all repairs based upon a careful consideration of the exponential, rather than additive, effects of multi-organ disease on post-cardiac surgery outcomes in neonates.

Four right ventricle to pulmonary artery conduit types

ObjectiveThe most durable valved right ventricle to pulmonary artery conduit for the repair of congenital heart defects in patients of different ages, sizes, and anatomic substrate remains uncertain. MethodsWe performed a retrospective analysis of 4 common right ventricle to pulmonary artery conduits used in a single institution over 30 years, using univariable and multivariable models of time-to-failure to analyze freedom from conduit dysfunction, reintervention, and replacement. ResultsBetween 1988 and 2018, 959 right ventricle to pulmonary artery conduits were implanted: 333 aortic homografts, 227 pulmonary homografts, 227 composite porcine valve conduits, and 172 bovine jugular vein conduits. Patients weighed 1.6 to 98.3 kg (median 15.3 kg), and median duration of follow-up was 11.4 years, with 505 (52.2%) conduits developing dysfunction, 165 (17.2%) requiring catheter intervention, and 415 (43.2%) being replaced. Greater patient weight, conduit z-score, type and position, as well as catheter intervention were predictors of freedom from replacement. Multivariable analysis demonstrated inferior durability for smaller composite porcine valve conduits, with excellent durability for larger diameter conduits of the same type. Bovine jugular vein conduit longevity was inferior to that of homografts in all but the smallest patients. Freedom from dysfunction at 8 years was 60.7% for aortic homografts, 72% for pulmonary homografts, 51.2% for composite porcine valve conduits, and 41.3% for bovine jugular vein conduits. Judicious oversizing of the conduit improved conduit durability in all patients, but to the greatest extent in patients weighing 5 to 20 kg. ConclusionsPulmonary and aortic homografts had greater durability than xenograft conduits, particularly in patients weighing 5 to 20 kg. Judicious oversizing was the most significant surgeon-modifiable factor affecting conduit longevity.

The Ross Procedure

The Ross procedure provides excellent long-term survival, hemodynamics, freedom from valve-related complications, and quality of life. However, its usage has decreased mainly because of concerns with technical complexity and long-term durability. In the last 2 decades, the factors associated with late failure after the Ross procedure have been clearly identified. As a result, the surgical technique has been modified in order to address these issues, specifically aiming at stabilizing the autograft root at its different levels: annulus, sinus of Valsalva, and sinotubular junction; as well as mitigating the risk of pulmonary homograft dysfunction. We have implemented this systematic approach over the last decade with demonstrated safety and effectiveness. Furthermore, by breaking down the operation into its smaller steps, we believe it makes it highly reproducible in the hands of dedicated aortic reconstructive surgeons. This article details our step-by-step, systematic, and tailored approach to the Ross procedure in patients with aortic stenosis or regurgitation.

The University of North Carolina Heart-Lung Transplant Experience: Historical Perspective and Notes on Surveillance for Very Long-Term Survivors

Background: The University of North Carolina (UNC) pioneered heart-lung transplant (HLT) in the state of North Carolina in 1991. Specific guidelines for surveillance of very long-term survivors of HLT are non-existent. We report historical context for the UNC 30-year experience with HLT, complexity of subsequent medical care, and a standardized approach to follow-up. Methods: The medical and UNOS records for all patients who underwent HLT at UNC were reviewed. Demographics, perioperative details, and post-transplant medication regimens were abstracted. Early (30 day) and late (>30 days post HLT) morbidity was described, and Kaplan-Meier curves estimated long-term survival. Results: Overall, 15 patients (67% male, 73% adults) underwent HLT, and 80% had congenital heart disease. Five-, twenty-, and twenty-five-year survival was 40% (n=6), 27% (n=4), and 20% (n=3), respectively. All 15-year survivors (n=5) experienced late complications (infections-100%; chronic kidney disease-60%; malignancies-40%; and pulmonary allograft rejection-60%). None had cardiac graft rejection. Dedicated transplant cardiologists and pulmonologists directed long-term care, and survivors were followed every 6-12 months with non-invasive cardiopulmonary testing. Invasive testing with cardiac catheterization and/or bronchoscopy was performed every 2-3 years. Limitations: Limitations of the study include small sample size typical of a single-center study. However, this historicallysignificant series represents the entire HLT experience at UNC. Conclusion: UNC pioneered HLT in the state of North Carolina in 1991. HLT remains a rarely-performed, but viable option for end-staged cardiopulmonary failure as evidenced by favorable long-term survival. Late complications are common and warrant close surveillance and ongoing coordinated care by a specialized multi-disciplinary team.

Results of large pulmonary homograft implantation for right ventricular outflow tract reconstruction.

To evaluate the long-term results of implantation of homogeneous large size of pulmonary homograft (PH) for reconstruction of the right ventricular outflow tract (RVOT). Between January 2000 and December 2017, 107 patients were implanted with PH for reconstruction of the RVOT. Data were collected retrospectively in this single-center study. PH failure was defined as a peak of gradient greater than 40 mmHg and/or as a pulmonary regurgitation greater than Grade 2. Primary endpoint was the reoperation of the RVOT during follow-up. Secondary endpoints were overall survival, occurrence of PH failure and the rate of reoperation for all cause. Mean age of the recipients was 26.1 ± 13.6 years. Median follow-up interval was 2.99 years (interquartile range [IQR]: 6.2). Mean size of PH was 24.9 ± 1.9 mm. Reoperation of the RVOT occurred in eight patients (7.8%). Time before reoperation was 2.74 years (IQR: 6.4). Freedom from reoperation for RVOT at 5 and 10 years was respectively 95.7% and 90.0%. Overall survival at 10 years was 95.2%. PH failure occurred in 13 patients (12.0%). Median time before PH failure was 6.7 years (IQR: 9.6). Freedom from PH failure at 10 years was 81.6%. Reoperation for PH failure occurred in four patients (3.9%). Concomitant tricuspid surgery (p = .01; 95% confidence interval [CI]: 1.9-319.6) and undersized PH (p = .01; 95% CI: 2.06-719.8) were independent risk factors of late reoperation. Implantation of large PH for RVOT reconstruction provides excellent midterm results in terms of reoperation.

Erupted abscess cavity and stenosed pulmonary homograft in repeated radical sternotomies: Anaesthesia and haemodynamics control

Congenital heart disease affects approximately 1% of the population and is the leading cause of birth defect associated infant illness and death. The most common cyanotic heart disease is tetralogy of Fallot (TOF) which is characterized by overriding of aorta, ventricular septal defect (VSD), pulmonary stenosis and right ventricular hypertrophy. TOF are repaired early in infancy and involves closure of the VSD and repair or replacement of the pulmonary valve to improve right ventricular outflow. A potential and significant complication is stenosis of the pulmonary homograft. We discuss a young patient with previous sternotomies for repair of TOF presenting for his 4th redo-sternotomy for an infective abscess near his old pulmonary homograft. This case presents to us multiple challenges such as a septic patient, previous sternotomies and a potential for intraoperatively massive blood loss. Keywords: Anaesthesia, Cardiac, Heart, Redo-sternotomy, Sepsis.

Dual Procurement of Lung and Heart Allografts Does Not Negatively Affect Lung Transplant Outcomes

BackgroundThe data that exists regarding multiorgan procurement outcomes is conflicted. Given the increasing demand for pulmonary allografts, it is critical to assess the impact of dual procurement on lung transplant recipient outcomes. MethodsThe United Network for Organ Sharing transplant registry was queried for all first-time adult (age ≥18) lung transplant recipients between 2006 and 2018 and stratified by concurrent heart donor status. Multiorgan transplant recipients and recipients with missing survival time were excluded. Donors were excluded if they were donating after circulatory death, did not consent or were not approached for heart donation, the heart was recovered for nontransplant purposes, or the heart was recovered for transplant but not transplanted. Post-transplant survival was analyzed using the Kaplan–Meier method and multivariable Cox proportional hazards regression. ResultsA total of 18,641 recipients met inclusion criteria, including 6230 (33.4%) in the nonheart donor group (NHD) and 12,409 (66.6%) in the heart donor group (HD). HD recipients demonstrated longer survival at 10 years posttransplant, with a median survival of 6.5 years as compared with 5.9 years in NHD recipients. On adjusted analysis, HD and NHD recipients demonstrated comparable survival (AHR 0.95, 95% CI 0.90-1.01). ConclusionsConcomitant heart and lung procurement was not associated with worse survival. This finding encourages maximizing the number of organs procured from each donor, particularly in the setting of urgency-driven thoracic transplantation.

Midterm results of homografts in pulmonary position: a retrospective single-center study.

Valved conduits play a pivotal role in the right ventricular outflow tract (RVOT) reconstruction in patients with congenital heart disease (CHD), and valved homografts have become the most commonly used conduits in pediatric cardiac surgery. This study aimed to assess the midterm performance of aortic and pulmonary homografts used in pulmonary position in patients with CHD. Ninety-eight patients underwent surgical RVOT reconstruction with a homograft from January 2012 to December 2017. We collected all patient details from the institute patient record system. Echocardiographic data were obtained from the records. Postoperative data included survival and follow-up echocardiography. The primary endpoints of the study were homograft failure, homograft dysfunction, and freedom from re-intervention. We observed allograft failure in two patients (2%), one each due to pseudo-aneurysm formation and infective endocarditis. There were 8 early deaths (8/98, 8.2%) and 9 late deaths (9/98, 9.2%). The mean survival time was 6.1years, and the postoperative survival rate at 1 and 5years was 89.73% and 82.65%, respectively. Homograft regurgitation and homograft dysfunction were higher in the pulmonary homograft group. However, the re-intervention rates were more in the aortic homograft (24.24%) group due to the higher incidence of calcification associated with them. Homografts used for RVOT reconstruction provide excellent intermediate-term outcomes, irrespective of the type of homograft used. Pulmonary homografts are more durable than aortic homografts and provide satisfactory results even in infants.