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Ann Thorac Surg 2004;77:1707-1710
© 2004 The Society of Thoracic Surgeons

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Original article: cardiovascular

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

^a Cardiac Unit, Royal Liverpool Children's Hospital, Liverpool, England, UK

Accepted for publication October 2, 2003.

^* Address reprint requests to Dr Purohit, Paediatric Cardiac Surgery, Alder Hey Hospital, Eaton Rd, Liverpool L12 2AP, UK, UK
e-mail: drpurohitm{at}yahoo.com

	Abstract

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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.

	Introduction

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The Ross procedure is widely accepted for treating both congenital and acquired aortic valve anomalies. The use of a patient's own valve, excellent hemodynamics, low thromboembolic risk, low incidence of endocarditis, avoidance of antithrombotic therapy, and potential of growth of autograft has popularized its application in the pediatric population [1, 2]. Pulmonary and aortic homografts are the most commonly used conduits for the restoring right ventricle to pulmonary artery continuity after the autotransplantation of the pulmonary valve to the aortic position [3, 4]. Constrains of availability of homografts has forced surgeons to search for alternatives [5].

The Contegra (Medtronic Inc, Minneapolis, MN) xenograft conduit is a bovine jugular vein fixed with glutaraldehyde. It has a natural trileaflet valve in the center of the conduit with generous length on both sides. Early clinical results of its use for right ventricular outflow tract repair in congenital anomalies and Ross procedure are encouraging [5, 6].

For this report we evaluated our results with the Contegra conduit for right ventricle to pulmonary artery reconstruction in 20 consecutive patients after Ross procedures.

	Material and methods

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Patients
Between November 2000 and June 2003, 20 patients underwent Ross procedures with a Contegra as a right ventricle to pulmonary artery conduit; homografts were not available. The median age at surgery was 14.4 years (range 3.8 to 55 years). Nine patients were older than 16 years and 11 were younger than 16 years, 2 of whom were younger than 5 years at operation. The median weight at surgery was 58.7 kg (range 11.5 to 125 kg). Seven patients had undergone previous surgical procedures. Eight patients had prior balloon dilation of the aortic valve (6 patients had one prior dilation, 2 more than one).

The preoperative demographic profile and intraoperative and postoperative data of various age groups are summarized in Table 1.

Echocardiography
Transthoracic two-dimensional echo and Doppler echocardiography was used to evaluate patients for the performance of the Contegra conduit. We assessed velocity across the conduit, peak gradient calculated by the modified Bernoulli equation, and conduit valve regurgitation. A predischarge echocardiogram was taken as a baseline measure and echocardiogram was performed at follow-up, paying special attention to increasing velocity and development of regurgitation.

Statistical analysis
All data were recorded and analyzed, expressed as mean, median, and standard deviation.

	Results

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Follow-up was 100% with a mean follow-up duration of 13.8 ± 9.12 months (range 1 to 31 months). No mortality or conduit-related morbidity occurred during follow-up. On the last follow-up all the patients were asymptomatic and none had any reoperation. No anticoagulation therapy was given postoperatively.

The mean velocity at discharge was 1.87 ± 0.30 m/s, giving a peak gradient in range of 4 to 21 mm Hg. The mean velocity at last follow-up was 1.91 ± 0.30 m/s. Only 1 patient had a velocity of more than 2.5 m/s at the main pulmonary arteries, but no significant progression occurred during the follow-up. None of the patient had a progressive rise in velocity and gradient during follow-up (Table 2).

One patient who underwent cardiac catheterization and angiography for persistent ST segment elevation noted electrocardiographically was found to have a normally functioning conduit (Fig 1). No abnormal coronary findings were noted, and the patient remained asymptomatic at last follow-up.

View larger version (144K): [in this window] [in a new window]   Fig 1. Lateral view of right ventricular angiocardiogram demonstrating adequately functioning Contegra valved conduit.

	Comment

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Pulmonary homografts were the conduit of our choice for reconstruction in Ross procedures from the beginning and remain so even today. More recently, demand has increased for homografts and at the same time organ donations have diminished; this relative lack of availability of homografts has precluded their widespread use and has lead to a search for alternative conduits. Thus we started using the new Contegra bovine jugular vein conduit. The Contegra conduit is a biological conduit, obtained by fixing a valved segment of bovine jugular vein with low-concentration buffered glutaraldehyde at very low pressure which is then further sterilized. The conduit is available in 12- to 22-mm sizes and comes with natural integral trileaflet venous valve in the center of the conduit. The central position of the valve with a generous conduit length on both sides provides some unique tailoring options and at the same time facilitates reconstruction without the need of additional material for proximal or distal extension. Care must be taken in positioning the valve in the right ventricular outflow tract, as the valve has deep sinuses and will take considerable length. This careful positioning is more important in the pediatric age group. Among older patients the ventricular end of the Contegra conduit needs some enlarging in order to adjust its diameter to the much larger opening on the right ventricle, left by the removal of the pulmonary root. The Contegra conduit is also available in a supported model, in which two external cloth-covered polypropylene rings support either side of the valve. We have no experience with this model, however.

Experimental results have shown excellent hemodynamics, satisfactory valve function by retaining flexibility and strength of the leaflets, and absence of any significant degenerative changes [7, 8]. The fixation technique has also been postulated to be beneficial for preventing calcification [9].

Early and intermediate clinical results from use of the Contegra conduit for congenital surgeries and during Ross procedure are encouraging [5, 6, 9–11]. In one report of the Contegra in the Ross procedure the hemodynamic performance of the Contegra graft was found to be better than that of the homograft, although the homografts were bigger in diameter [5, 9]. Studies of complex congenital repair of the right ventricular outflow tract using the Contegra graft have also documented similar performance when compared with homografts [6, 10, 11]. The follow-up in these studies (maximum 27 months) is not long enough to indicate the longer-term results. Early complications in the form of nonfatal and fatal thrombosis, aneurysmal dilation, confluence stenosis, and endocarditis requiring reoperation have been described after its use for congenital defect repairs [10, 12]. However, these patients represent a totally different subset from those undergoing Ross procedure as described in this report. Both immunologic and nonimmunologic mechanisms have been postulated and the need for close follow-up has been emphasized [12].

In our experience during this limited follow-up period, all the conduits remained free of any complication. They have shown adequate valve function and there was no finding suggestive of conduit failure in the form of obstruction, dilation, or calcification. Our results are in accordance with other studies of the Contegra conduit in the Ross procedure [5, 7].

The mean follow-up of 13.8 months (range 1 to 31 months) is a short period in the natural history of any conduit. Thus the excellent results at this follow-up cannot be extrapolated to predict the longer-term results of the conduit. The actual longer-term results can only answer questions regarding durability. We plan continuous close follow-up, including magnetic resonance scanning of all the patients with Contegra conduits, as echocardiographically measured velocities may involve potential errors.

Satisfactory hemodynamics, excellent handling characteristics, ease of availability, and encouraging clinical results makes the Contegra bovine jugular vein conduit a viable alternative to the homograft in Ross procedure.

	References

Top Abstract Introduction Material and methods Results Comment References

 

1. Chambers J.C., Somerville J., Stone S., Ross D.N. Pulmonary autograft procedure for aortic valve disease. Circulation 1997;96:2206-2214.[Abstract/Free Full Text]
2. Elkins R.C., Lane M.M., McCue C. Ross procedure in children: late results. J Heart Valve Dis 2001;10:736-741.[Medline]
3. Ross D.N. Options for right ventricular outflow tract reconstruction. J Card Surg 1998;13:186-189.[Medline]
4. Carr-White G.S., Kilner P.J., Hon J.K.F., et al. Incidence, location, pathology, and significance of pulmonary homograft stenosis after the Ross operation. Circulation 2001;104:I16-20.
5. Corno A.F., Hurni M., Griffin H., Jeanrenaud X., von Segesser L.K. Glutaraldehyde-fixed bovine jugular vein as a substitute for the pulmonary valve in the Ross operation. J Thorac Cardiovasc Surg 2001;122:493-494.[Free Full Text]
6. Breymann T., Thies W.R., Boethig D., et al. Bovine valved venous xenografts for RVOT reconstruction: results after 71 implantations. Eur J Cardiothorac Surg 2002;21:703-710.[Abstract/Free Full Text]
7. Ichikawa Y., Noishiki Y., Kosuge T., et al. Use of bovine jugular vein graft with natural valve for right ventricular outflow tract reconstruction: a one-year animal study. J Thorac Cardiovasc Surg 1997;114:224-233.[Abstract/Free Full Text]
8. Scavo V.A., Turrentine M.W., Aufiero T.X., et al. Valved bovine jugular venous conduits for right ventricular pulmonary artery reconstruction. ASAIO J 1999;45:482-487.[Medline]
9. Corno A.F., Hurni M., Griffin H., et al. Bovine jugular vein as right ventricle-to-pulmonary artery valved conduit. J Heart Valve Dis 2002;11:242-247.[Medline]
10. Carrel T., Berdat P., Pavlovic M., Pfammatter J.P. The bovine jugular vein: a totally integrated valved conduit to repair the right ventricular outflow. J Heart Valve Dis 2002;11:552-556.[Medline]
11. Bové T., Demanet H., Wauthy P., et al. Early results of valved bovine jugular vein conduit versus bicuspid homograft for right ventricular outflow tract reconstruction. Ann Thorac Surg 2002;74:536-541.[Abstract/Free Full Text]
12. Boudjemline Y., Bonnet D., Massih T.A., et al. Use of bovine jugular vein to reconstruct the right ventricular outflow tract: early results. J Thorac Cardiovasc Surg 2003;126:490-497.[Abstract/Free Full Text]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Manoj Purohit Marco Pozzi Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Purohit, M. Articles by Pozzi, M. Search for Related Content PubMed PubMed Citation Articles by Purohit, M. Articles by Pozzi, M. Related Collections Valve disease