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Ann Thorac Surg 2005;80:655-664
© 2005 The Society of Thoracic Surgeons
Section of Cardiothoracic Surgery, James W. Riley Hospital for Children and Indiana University School of Medicine, Indianapolis, Indiana
Accepted for publication February 9, 2005.
* Address reprint requests to Dr Brown, Section of Cardiothoracic Surgery, Indiana University School of Medicine, 545 Barnhill Dr, EH 215, Indianapolis, IN 46202-5123 (Email: jobrown{at}iupui.edu).
Presented at the Fortieth Annual Meeting of The Society of Thoracic Surgeons, San Antonio, TX, Jan 26–28, 2005.
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Abstract |
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 Top Abstract IntroductionPatients and MethodsResultsCommentDiscussionReferences |
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METHODS: Between January 1985 and December 2003, 117 non-Ross patients received AC (94 pulmonary and 23 aortic) for RVOT reconstruction. Median age at implantation was 8 months (mean 4.3 ± 7.1 years; range, 6 days to 43 years). There were 57 children (49%) less than 12 months of age. Endpoints were AC failure (valve explant, balloon dilatation), and AC dysfunction (AC stenosis >40 mm Hg and AC insufficiency more than 2+). There were no device-related deaths.
RESULTS: Overall patient survival was 80% at 15 years. Freedom from AC failure was 60% at 5 years and 43% at 15 years. Freedom from failure was worse in infants (42% and 34% at 5 and 15 years, respectively). Freedom from AC dysfunction was 40% at 5 years and 23% at 15 years. Freedom from dysfunction was worse in infants (21% and 16% at 5 and 15 years, respectively). Univariate analysis identified younger patient age, smaller AC size, diagnosis of truncus arteriosus, and the presence of aortic AC as risk factors for AC dysfunction and failure. Multivariate analysis identified smaller AC size and the presence truncus arteriosus as risk factors for AC dysfunction and failure.
CONCLUSIONS: Right ventricular outflow tract reconstruction with an AC in non-Ross patients has poor performance at midterm follow-up with AC dysfunction and failure of, respectively, 60% and 40% for the entire group and 79% and 58% in the infant group at 5 years. An alternate conduit for this application must be considered.
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Introduction |
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TopAbstractIntroductionPatients and MethodsResultsCommentDiscussionReferences |
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Because of the lack of allograft availability and problems with preservation and storage in North America, the use of porcine-valved Dacron conduits was favored through the early 1980s [3]. Late complications, however, led to decreased use of porcine-valved Dacron conduits. The cryopreserved allograft subsequently became the conduit of choice in the United States for RVOT reconstruction in the mid 1980s. Development of cryopreservation techniques has improved the availability and durability of allografts considerably, resulting in increasing utilization in clinical practice. Early results with allograft conduits (AC) for reconstruction of the RVOT in congenital heart disease have been good, but there are few long-term studies reporting AC dysfunction and failure [4–6].
Children undergoing the Ross procedure are usually older and have their AC inserted in the orthotopic position as opposed to the heterotopic position used for most cases of complex RVOT reconstruction. The orthotopic position of the AC combined with the fact that the AC in the Ross procedure are larger diameter and can be oversized by several millimeters are the factors that increase AC durability in children undergoing the Ross procedure.
To further evaluate the risk factors for AC dysfunction and failure, a retrospective evaluation of our experience with the use of AC in non-Ross patients for reconstruction of the RVOT was conducted.
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Patients and Methods |
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TopAbstractIntroductionPatients and MethodsResultsCommentDiscussionReferences |
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Upon approval by the Indiana University Institutional Review Board for the use of human subjects’ research in compliance with federal regulations, medical records and clinical charts were reviewed for all AC valve recipients including operative records as well as preoperative and postoperative catheterization and echocardiography data. Data collected included diagnosis, previous operative procedures, age, sex, and weight at operation. Patient follow-up was obtained from hospital and clinic visit records. Follow-up information was available within the past 2 calendar years for 93% of surviving patients. Patients’ characteristics including diagnostic category, previous procedure, and age at initial allograft placement and subsequent operation are summarized in Table 1.
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Allograft dysfunction was defined as one of the following: moderate or greater stenosis (>40 mm Hg) or insufficiency greater than 2+ on echocardiography. Allograft failure was defined as explant of the AC for any reason, a requirement for balloon dilatation, or patient death. Allograft insufficiency was defined echocardiographically as moderate when there was a broad regurgitant jet less than the annulus width associated with diastolic color Doppler flow reversal from the distal main pulmonary artery. A regurgitant jet that encompassed the entire annulus width associated with diastolic flow reversal in the branch pulmonary arteries was graded as severe. Severe allograft stenosis was defined as a transvalvular peak pressure gradient greater than 40 mm Hg. The follow-up echocardiogram in which the patient first met one or both of these dysfunction criteria was recorded as the end of satisfactory allograft life and the beginning of AC dysfunction.
The surgical technique for both primary and reoperative procedures with AC has been described previously by Brown and associates [7]. Use of pulmonary homografts has been favored over aortic homografts since 1993. The appropriate allograft size was determined by standardized valve size charts, based on weight and body surface area. The larger end of the normal size range was favored in an attempt to use the largest allograft technically possible. All patients were placed on cardiopulmonary bypass. During allograft replacement procedures, all calcified tissues were removed. The distal anastomoses were performed using a combination of running and interrupted 5-0 or 6-0 Prolene suture (Ethicon, Somerville, New Jersey). Proximal anastomosis of the allograft to the right ventricular infundibulum was facilitated with the use of a hood. A variety of materials were used for the hood including glutaraldehyde-treated bovine pericardium, or synthetic material usually Gore-Tex (W.L. Gore and Assoc., Flagstaff, Arizona). Both proximal and distal anastomoses were performed with the cross-clamp off.
In all, 101 operative survivors were clinically followed up for 2 months to 15 years (mean follow-up, 6.1 ± 3.7 years) postoperatively (Fig 1). Two patients were lost to follow-up (follow-up complete in 98%). After discharge from the hospital, follow-up was conducted by pediatric cardiologists and cardiovascular surgeons. Symptomatic children were investigated by echocardiography and occasionally by catheterization. Asymptomatic children were often seen every other year. Indications for replacement of the initial allograft were conduit stenosis with a gradient greater than 40 mm Hg, RV pressures 75% or more of left ventricular pressure, or echocardiographic evidence of progressive RV dilation or tricuspid valve regurgitation, or both, associated with right heart failure due to allograft valve stenosis or insufficiency.
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Results |
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TopAbstractIntroductionPatients and MethodsResultsCommentDiscussionReferences |
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There were 7 late deaths (7 of 99, 7%). One patient died of bacterial endocarditis and necrotizing fasciitis 4 months after repair of truncus arteriosus, and a second patient died of aspiration pneumonia 1 year after truncus arteriosus repair. Both deaths were considered not related to the valve. A third patient underwent initial RV-PA conduit reconstruction with an aortic AC for truncus arteriosus and at reoperation, 8 months later, had an RV anastomotic aneurysm. A polytetrafluoroethylene (PTFE) monocusp and outflow patch was inserted to enlarge the main and left pulmonary arteries. Two years after reoperation, the child died of pneumonia. The 4 remaining late deaths were attributed to unknown causes in 2 patients and were secondary to noncardiac illness in 2 patients. An actuarial survival curve that includes hospital mortality for patients who underwent AC placement demonstrates a relatively constant survival of 80% at 5, 10, and 15 years (Fig 2A).
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Thirteen patients (13 of 41; 32%) had RVOT stenosis at multiple levels. Eleven patients with branch pulmonary stenosis underwent surgical angioplasty of the right and left pulmonary arteries employing Gore-Tex or pericardial patches or balloon angioplasty. Eight of the 11 with multilevel stenosis underwent conduit replacement 1.6 ± 1.1 years (range, 1 month to 3 years) after the initial surgery.
Of the original 23 aortic homograft conduits in this series, there were 5 early deaths and 18 early survivors of whom 14 (78%) have required conduit replacement. Of the original 94 pulmonary homografts, there were 11 early and 7 late deaths, and 2 patients were lost to follow-up. Twenty-seven of the 74 surviving patients (37%) have required conduit replacement. The difference between durability of aortic and pulmonary AC was highly significant (p = 0.003).
Allograft Dysfunction
Seventy patients surviving the initial conduit insertion (70 of 99, 71%) had evidence of significant allograft dysfunction (gradient >40 mm Hg or >2+ regurgitation, or both) at the recent follow-up or before conduit replacement. Of these 70 patients with conduit dysfunction, 45 (64%) have had the allografts replaced and are included among the AC failures. Twenty-five children (35%) have AC dysfunction but have not yet had their AC replaced. Only 29 patients (41%) have acceptable function of their original AC at last follow-up.
Actuarial freedom from allograft dysfunction was 40% at 5 years and 23% at 15 years for the whole series (Fig 3A). Freedom from dysfunction was significantly worse in infants (21% and 16% at 5 and 15 years, respectively; p = 0.001). Patients receiving aortic AC had a higher frequency of dysfunction than patients receiving pulmonary AC at 15 years (aortic 12% vs pulmonary 31%; p < 0.05). We further observed that homograft diameter less than 12 mm was a significant predictor of dysfunction (<12 mm 92%, >12 mm 74%; p = 0.004) at 15 years. Univariate analysis identified younger patient age (p = 0.0008), and the presence of aortic homograft (p = 0.0005) as risk factors for AC dysfunction. By multivariate analysis, the use of smaller AC size (p = 0.001) and diagnosis of truncus arteriosus (p = 0.001) were the only significant risk factors for AC dysfunction (Table 3).
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By univariate analysis, younger patient age (<1 year; p = 0.04), smaller AC size (<12 mm; p = 0.01), diagnosis of truncus arteriosus (p = 0.009), and presence of aortic allografts (p = 0.001) were significant predictors of conduit failure. However, by multivariate analysis the diagnosis of truncus arteriosus alone (p = 0.001) was associated with an increased incidence of AC failure (Table 2).
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Comment |
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TopAbstractIntroductionPatients and MethodsResultsCommentDiscussionReferences |
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The development of cryopreservation techniques combined with improved availability created widespread use of allografts for reconstruction of the RVOT in congenital heart disease. Until recently, cryopreserved allografts have been the best valved conduits for reconstruction of the RVOT. The limited durability of the AC became evident within a few years (early 1990s). A number of studies have documented allograft failure [4–6, 10–14] (Table 4). These studies have not reported or have underestimated the incidence of AC dysfunction.
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Primary repairs in the newborn period or infancy were frequent in our series and included 52 patients undergoing repair of truncus arteriosus. Limitations of allograft size that can be implanted in neonates, infants, and small children will predictably result in the need for conduit replacement as the child grows [12, 16, 17]. Perron and associates [18] reported that in small patients, size and outgrowth overwhelm allograft type as a predictor of failure. Wells and colleagues [5] demonstrated that considerable shrinkage of AC was the predominate cause for its failure. They believed that the size reduction was immune-response mediated. Hawkins and colleagues [15], Elkins [19], and others have demonstrated that panel reactive antibodies levels consistently rise after AC insertion and that this response is greatly reduced by removing the AC endothelium, namely, Synergraft technology (CryoLife). We have implanted Synergraft pulmonary allograft in 40 patients since 2000. This notion is not supported by studies looking at humoral and T-cell responses to valved allografts in children [15, 20]. It makes sense that perhaps smaller donor and recipient size could contribute to increased valve dysfunction solely based on different growth rates between smaller and larger patients. However, Tweddel and coworkers [6] have argued against this by showing that the net change in allograft annular Z-value (–1.2 ± 1.3 vs –1.4 ± 1.1; p = not significant), from implantation to last follow-up, was not significantly different between a group of patients with and without allograft dysfunction or failure.
In some AC recipients, immunologic response could manifest itself as a low-grade rejection slowly occurring over years. Such a response would reduce the durability of the AC [9]. Our AC donors and recipients were not matched for ABO blood group or human leukocyte antigens, and immunosuppressive therapy was not given to any valve recipient at any time. Observations of other groups have not demonstrated that blood group incompatibility influences the durability of allografts. Immunosuppressive treatment to reduce the immunogenicity of the allograft valve has not been shown to improve the long-term results after implantation [19, 20]. The limited supply of pulmonary homografts in the pediatric size range has prohibited ABO compatibility considerations. When available, an attempt was made to use the most compatible homograft. The article by Clarke and colleagues [21] is the only report we have found to show relationship of accelerated fibrocalcification to ABO compatibility.
Long-term functional differences between the pulmonary and aortic allografts have been described by Bando and associates [13]. These results indicate that aortic and pulmonary allografts provide excellent short-term patient survival after RVOT reconstruction, but pulmonary allografts are more durable than aortic allografts and are associated with less calcification and obstruction. Bando’s results corroborate other published data including our observations in this report that advocate the use of pulmonary AC, rather than aortic AC, to reconstruct the RVOT unless the pulmonary vascular resistance is chronically high (>7 Wood units). In recent years, we have totally avoided the use of aortic AC for RVOT reconstruction in favor of a xenograft valve or conduit, or both, in patients with chronically elevated pulmonary vascular resistance.
Recent reports suggest that the durability of allografts has decreased in the current era. Niwaya and associates [12] identified later year of operation as a risk factor for allograft failure. Stark and associates [22] noted that allograft replacement was associated with a higher risk of failure than the original allograft. We have avoided using second AC in our patients (only 3) because of this concern. Possible explanations for this observation include a heightened immune response due to more viable endothelial cells in CryoLife AC, broadening of the indications for allograft placement including younger patients with more complex lesions and a decreased threshold for replacement of a dysfunctional AC.
Allograft insufficiency was the primary indication for conduit replacement in only 1 patient in our series, but significant regurgitation was universally present. In fact, insufficiency is probably an important contributing factor to conduit dysfunction because the additional volume load that comes with valve regurgitation increases the RV stroke volume and increases the gradient across a stenotic conduit. Therefore, preservation of pulmonary valve structural integrity is important in prolonging allograft durability. Kanter and colleagues [23] have suggested the use of cardiac magnetic resonance imaging for quantitating the severity of regurgitation and AC failure. They recommend reoperation for AC dysfunction when the RV volume becomes greater than two times the LV volume.
Wells and colleagues [5] described several potential causes for early AC dysfunction and failure. They pointed out the potentially important technical issue involving the positioning of the proximal conduit anastomosis. If the proximal allograft is sewn posterior to the epicardial aspect of the right ventriculotomy, it tends to sit much higher (extracardiac). A hood is then needed to provide a smooth outflow tunnel. This extracardiac positioning would seem more susceptible to sternal compression and allograft valve distortion. This theory might help explain why the AC is more durable in the Ross patients than in patients with complex congenital heart disease. Wells further documented the immunologic basis of AC diameter shrinkage commonly observed by others and us. He demonstrated that AC shrinkage increased the RV-PA gradient and led to early AC dysfunction and that AC failure was not solely due to somatic outgrowth.
The Ross patients’ older age and larger body size, the orthotopic position of the AC, and the fact that the AC in the Ross procedure can be oversized by several millimeters are the three factors that increase AC durability in the Ross group. In our series of more than 150 Ross operations, of which 70 were in children, only 3 have required reoperations for AC dysfunction or failure over our 12-year experience [7]. Other groups have also reported similar low failure rates in their pediatric Ross series [10, 12]. That the median age of the patients in our non-Ross series was 8 months with a mean age of 4 years, whereas the median age of our pediatric Ross series was 12 years with a mean age of 7 years, demonstrated the older age and obvious larger size of patients undergoing the Ross procedure.
The search continues for a better extracardiac conduit. Several centers have advocated using a stented [8, 24–26] or nonstented porcine aortic or xenograft pericardial valve inside a pericardial or Gore-Tex tube for patients older than 10 years. We have utilized both techniques and have found them satisfactory in older children and adults. However, the bulk and rigidity of the valve ring and frame in the stented porcine or pericardial valve reduces the valve orifice area and increases the risk of transmitting sternal compression through the conduit to the left coronary artery. The stentless porcine valve as advocated by Kanter and coworkers [23] and Hartz and colleagues [26] has a stiff aortic wall support and eliminates the prosthetic frame and the concern of sternal compression. In our opinion, the absence of a stent allows placement of a valve with a larger valve area. We have recently used several stentless porcine roots (Medtronic-Freestyle) as an RV-PA conduit, and they have worked well in older children and adults. The stentless aortic root in our opinion is too stiff and noncompliant for infants and younger children, and they nearly always require addition of a proximal hood to facilitate the RV connection.
The Shelhigh porcine pulmonary RV-PA conduit initially looked promising, but early experience in some centers have shown a high failure rate (>50%) in infants and small children less than 1 year of age [27, 28]. The reasons for their accelerated dysfunction are not yet explained. We have had no experience with the Shelhigh conduit.
The PTFE monocusp with separate RVOT outflow patch has been very useful for our patients with tetralogy of Fallot who require a transannular patch and for patients requiring a second RVOT procedure after a failed AC reconstruction (22 patients in this report). The monocusp has functioned very well in most patients for the first 1 to 3 years and for as long as 10 years in some patients and has not produced RVOT obstruction. Continued function of the monocusp persists, but some regurgitation develops as the RVOT grows [29]. We believe that the PTFE monocusp reconstruction of a failed AC is preferable to using a second AC. Although the monocusp develops some regurgitation over time, it is better than no valve, and it has not produced recurrent obstruction as is seen with second ACs.
Our recent experience with the glutaraldehyde-preserved bovine jugular venous valved conduits (Contegra) for RVOT reconstruction has been extremely encouraging. The Contegra is currently in clinical trials in the United States in 10 centers and was released by the US Food and Drug Administration for humanitarian device exemption (HDE) in November 2003 and can now be used by any US surgeon under HDE provisions. This conduit is available in sizes 12 to 22 mm, comes with or without external ring supports, and has adequate tissue length (5 cm) proximal and distal to the conduit valve to facilitate PA patch plasty or RV connection. The conduit has handling qualities that are very favorable. The follow-up remains short (2 months to 4 years). Only 1 of the 50 children who have received the Contegra conduit at our center have required replacement, and 8 have been used in newborns with truncus arteriosus. The one reoperation was due to a RV pseudoaneurysm at the proximal suture line.
Although there are some European reports that show a significant incidence of distal conduit stenosis, we and Breymann [30] have not encountered this complication. The high frequency of distal anastomosis stenosis may be related to inadequate removal of glutaraldehyde from the conduit prior to implantation or represent purse-string anastomotic narrowing during insertion. We have always employed low-dose aspirin, 10 mg/kg body weight, to prevent any accumulation of platelets or other cellular elements from adhering to anastomosis in all types of RV-PA conduits.
In several European patients, the Contegra conduit has been mounted into a large vascular stent and successfully inserted percutaneously into the RVOT [31].
Despite all their limitations, RVOT conduits have allowed the vast majority of patients to survive repair of complex congenital cardiac defects. Allograft conduits for the RVOT have satisfactory short-term function, but their function at midterm is unsatisfactory. The ideal conduit is one that has excellent long-term valve durability, absence of shrinkage, and the potential for somatic growth (tissue-engineered conduits).
Elkins [19], in a recent review of tissue engineered RV-PA conduits, suggested that considerable progress has been made with reference to biodegradable scaffolds and decellularized allograft as well as xenograft conduits seeded with autologous cells. Most of the data are preclinical and short-term [32]. A limited number of allograft and xenograft decellularized RV-PA conduits have been implanted in patients. Short-term follow-up (<3 years) is forthcoming. The need for reoperation even with tissue-engineered conduits may be inevitable, because a scarred mediastinum may inhibit conduit growth. We must continue research for a better conduit, but in the mean time, keep the risk of reoperation and reintervention low so our patients can enjoy a good quality and quantity of life.
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Discussion |
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TopAbstractIntroductionPatients and MethodsResultsCommentDiscussionReferences |
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DR BROWN: Not at all. Because the mean age for our Ross patients was 10. And it’s just basically showing that age and size of the patient is probably the major difference.
The other point we wanted to make, that if you can put the allograft in the orthotopic position like you can in a Ross, that decreases turbulence in the conduit and I think heightens its durability.
The other thing that the Ross group allows us to do is we can oversize the allograft to a much greater degree than we can in the young infant where you can’t cram an 18 allograft conduit in a 4 kg baby.
So all of these factors come up. But just basically to say that the allograft conduit for the larger, older patient, when you can place it in the orthotopic position, is likely to fare much better than in this younger child with complex congenital heart disease.
DR MONRO: I may have missed it, but did you tell us how you prepared the homografts? Were they relatively fresh or cryopreserved?
DR BROWN: These are all Cryolife conduits, which is what we’ve had available to us in the States. So they’re all cryopreserved.
DR MONRO: I think that they don’t survive as well as the antibiotic sterilized homografts we used in the past, some of which are still in position. In fact, the longest survival is an aortic homograft that I put in a 7-week-old baby with truncus arteriosus and replaced 26 years later. So I think we really should perhaps think of going back to preparing the valves as we used to.
DR BROWN: Well, the fact that there is viable endothelium on some of these cryopreserved homografts I think has caused even Cryolife to try to take the endothelium away, utilizing the xenograft technology. So I think yes, there is much to learn about this whole process.
DR GERHARD ZIEMER (Tuebingen, Germany): John, I have one question and one comment. What is dysfunction? Was this stenosis only? If so, this would explain that a 10-mm or a 12-mm homograft will not work after 15 years. Accordingly, it is not surprising that whatever nongrowing device you use in infancy will not last that long. We should rather call it outgrowth instead of dysfunction!
My comment is about the differences in Ross versus non-Ross patients. Isn’t this primarily a question of positioning of the homograft? Most of the patients will have a more or lesser degree of distortion of the homograft when it is inserted on the right ventricular outflow tract employing an infundibulotomy. Whereas in the Ross procedure, you really have almost an orthotopic implantation, which leaves you with a rather ideal positioning of the homograft. In addition, as Jim Monroe just said, for older Ross patients, age and procedure would significantly help them to have better RV-PA outcomes than younger non Ross patients have.
DR BROWN: Well, thank you for your comment. You’re right on. There’s no question. First of all, we considered dysfunction as one or the other or both. If you had greater than a 40-mm gradient or you had greater than 2-plus regurgitation, we considered that dysfunction. And so either one was considered dysfunction.
There is no question that patients undergoing the Ross procedure, the conduit or the allograft is placed in the orthotopic position, which we feel makes a major difference. In the heterotopic position, there is more turbulence. And I think I tried to point that out in my conclusions, and it’s borne out in the manuscript as well.
DR FRANCOIS LACOUR-GAYET (Denver, CO): I enjoyed very much your presentation and share your concern about homografts. Have you seen in your series very early homograft dysfunction? I’m talking of patients who have a massive regurgitation 3 weeks after implantation especially in the neonatal group after truncus or pulmonary atresia and VSD repair. When reoperating on these patients, all leaflets had totally disappeared, as if there was a very severe allograft rejection. Have you seen something similar?
DR BROWN: We, for sure, have seen the leaflets disappear. We think they get stuck out against the wall; and when you open the allograft conduit, you can’t even find leaflets. We see that in maybe half of the conduits that we reoperate on.
We, fortunately, have not seen the aneurysmal dilatation of an allograft conduit. I don’t know whether that has something to do with a difference in altitude between Denver and Indianapolis or not. But fortunately, we haven’t seen that and I hope we don’t.
DR ROBERT A. GUSTAFSON (Morgantown, WV): John, could you tell us your conduits of choice right now in your current practice?
DR BROWN: Can we show those last two discussion slides? I thought that might come up. Duke, you were right on.
I’ll just show you what our current practice is. For the most part, we’re using the Contegra for the babies, for all the newborns and that sort of thing. We think it’s a much more favorable conduit. That’s the bovine jugular venous valve conduit.
Obviously, when we can preserve the pulmonary valve by doing valvotomy, we’d always keep a native valve over a replacement valve.
In patients who don’t really need a conduit but need an outflow tract reconstruction, we still continue to use the Gore-Tex monocusp, in patients who require a transannular patch, and find that a very useful technique.
And again getting down to the bovine jugular vein in infants and younger children less than 10 years requiring a heterotopic conduit reconstruction, we’ll use the Contegra. And again, that’s just become available for all of us in the United States as of November, when you have to apply it to your IRB. It is HDE released, a humanitarian device exemption. So it is available to centers other than the 10 centers that have been involved with the initial studies.
And finally, we still use the pulmonary homograft for adolescents and adults when the orthotopic position can be maintained as in our Ross group. We think, why throw it away when it’s served us very well in our patients for more than 10 years. And I think our European colleagues, as well as Mr. Ross, have shown that the pulmonary homograft, for the most part, has held up very well.
We continue to use stented porcine or pericardial xenografts, or nonstented xenografts, the Medtronic freestyle, for older children greater than 5 years of age or adults requiring a heterotopic placement. We think that those valves work really very well.
And the only other comment that I’d make, since we don’t know what the long-term outcome of any of these conduits are for 10 or 15 years, we’re closing the pericardium in all of our conduits with Gore-Tex membrane so that we don’t hurt children when we have to go back in and reoperate on them.
DR CIA S. QUINTANA (San Juan, PR): Thank you very much for your presentation. If I understood your slides, in both your univariate and multivariate analysis, truncus arteriosus counts as a risk factor for early graft failure. Do you have any explanation for that?
DR BROWN: Well, they’re, by far, the very smallest and youngest groups. And they receive the very smallest conduits that we have available to us. I think that’s primarily the reason, more than anything else, and the fact that it’s a heterotopic placement.
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A. Ruffer, A. Purbojo, I. Cicha, M. Glockler, S. Potapov, S. Dittrich, and R. A. Cesnjevar Early failure of xenogenous de-cellularised pulmonary valve conduits -- a word of caution! Eur J Cardiothorac Surg, July 1, 2010; 38(1): 78 - 85. [Abstract] [Full Text] [PDF]
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J.-H. Yang, T.-G. Jun, K. Sung, W. S. Kim, Y. T. Lee, and P. W. Park Midterm Results of Size-Reduced Cryopreserved Homografts for Right Ventricular Outflow Tract Reconstruction Ann. Thorac. Surg., June 1, 2010; 89(6): 1821 - 1826. [Abstract] [Full Text] [PDF]
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 K. Asoh, M. Walsh, E. Hickey, M. Nagiub, R. Chaturvedi, K.-J. Lee, and L. N. Benson Percutaneous pulmonary valve implantation within bioprosthetic valves Eur. Heart J., June 1, 2010; 31(11): 1404 - 1409. [Abstract] [Full Text] [PDF]
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J. W. Brown, R. C. Elkins, D. R. Clarke, J. S. Tweddell, C. B. Huddleston, J. R. Doty, J. W. Fehrenbacher, and J. J.M. Takkenberg Performance of the CryoValve SG human decellularized pulmonary valve in 342 patients relative to the conventional CryoValve at a mean follow-up of four years. J. Thorac. Cardiovasc. Surg., February 1, 2010; 139(2): 339 - 348. [Abstract] [Full Text] [PDF]
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 R. Puranik, V. T. Tsang, A. Broadley, J. Nordmeyer, P. Lurz, N. Muthialu, G. Derrick, F. Walker, S. Cullen, M. de Leval, et al. Functional outcomes after the Ross (pulmonary autograft) procedure assessed with magnetic resonance imaging and cardiopulmonary exercise testing Heart, February 1, 2010; 96(4): 304 - 308. [Abstract] [Full Text] [PDF]
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E. Belli, E. Salihoglu, B. Leobon, F. Roubertie, M. Ly, R. Roussin, and A. Serraf The Performance of Hancock Porcine-Valved Dacron Conduit for Right Ventricular Outflow Tract Reconstruction Ann. Thorac. Surg., January 1, 2010; 89(1): 152 - 158. [Abstract] [Full Text] [PDF]
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I. George, J. N. Shah, M. Bacchetta, and A. Stewart Stentless Bioprosthesis in a Valved Conduit: Implications for Pulmonary Reconstruction Ann. Thorac. Surg., December 1, 2009; 88(6): 2022 - 2024. [Abstract] [Full Text] [PDF]
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J. Horer, M. Vogt, U. Stierle, J. Cleuziou, Z. Prodan, C. Schreiber, and R. Lange A Comparative Study of Mechanical and Homograft Prostheses in the Pulmonary Position Ann. Thorac. Surg., November 1, 2009; 88(5): 1534 - 1539. [Abstract] [Full Text] [PDF]
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J. Nordmeyer, V. Tsang, R. Gaudin, P. Lurz, A. Frigiola, A. Jones, S. Schievano, C. van Doorn, P. Bonhoeffer, and A. M. Taylor Quantitative assessment of homograft function 1 year after insertion into the pulmonary position: impact of in situ homograft geometry on valve competence Eur. Heart J., September 1, 2009; 30(17): 2147 - 2154. [Abstract] [Full Text] [PDF]
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L. Grosse-Wortmann and A. Redington Doing the right thing at the right time: is there more to pulmonary valve replacement than meets the eye? Eur. Heart J., September 1, 2009; 30(17): 2076 - 2078. [Full Text] [PDF]
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J. P.V. Zachariah, F. A. Pigula, J. E. Mayer Jr, and D. B. McElhinney Right Ventricle to Pulmonary Artery Conduit Augmentation Compared With Replacement in Young Children Ann. Thorac. Surg., August 1, 2009; 88(2): 574 - 580. [Abstract] [Full Text] [PDF]
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J. W. Brown, M. Ruzmetov, A. Shahriari, M. D. Rodefeld, Y. Mahomed, and M. W. Turrentine Midterm Results of Ross Aortic Valve Replacement: A Single-Institution Experience Ann. Thorac. Surg., August 1, 2009; 88(2): 601 - 608. [Abstract] [Full Text] [PDF]
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J. Horer, T. Hanke, U. Stierle, J. J.M. Takkenberg, A. J.J.C. Bogers, W. Hemmer, J. G. Rein, R. Hetzer, M. Hubler, D. R. Robinson, et al. Homograft Performance in Children After the Ross Operation Ann. Thorac. Surg., August 1, 2009; 88(2): 609 - 615. [Abstract] [Full Text] [PDF]
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 P. Lurz, J. Nordmeyer, V. Muthurangu, S. Khambadkone, G. Derrick, R. Yates, M. Sury, P. Bonhoeffer, and A. M. Taylor Comparison of Bare Metal Stenting and Percutaneous Pulmonary Valve Implantation for Treatment of Right Ventricular Outflow Tract Obstruction: Use of an X-Ray/Magnetic Resonance Hybrid Laboratory for Acute Physiological Assessment Circulation, June 16, 2009; 119(23): 2995 - 3001. [Abstract] [Full Text] [PDF]
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C. J. Bruce and H. M. Connolly Right-Sided Valve Disease Deserves a Little More Respect Circulation, May 26, 2009; 119(20): 2726 - 2734. [Full Text] [PDF]
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M. Ando and Y. Takahashi Ten-year experience with handmade trileaflet polytetrafluoroethylene valved conduit used for pulmonary reconstruction. J. Thorac. Cardiovasc. Surg., January 1, 2009; 137(1): 124 - 131. [Abstract] [Full Text] [PDF]
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J. W. Brown, M. Ruzmetov, M. D. Rodefeld, and M. W. Turrentine Right Ventricular Outflow Tract Reconstruction in Ross Patients: Does the Homograft Fare Better? Ann. Thorac. Surg., November 1, 2008; 86(5): 1607 - 1612. [Abstract] [Full Text] [PDF]
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A. C. Fiore, M. Rodefeld, M. Turrentine, P. Vijay, T. Reynolds, J. Standeven, K. Hill, J. Bost, D. Carpenter, C. Tobin, et al. Pulmonary Valve Replacement: A Comparison of Three Biological Valves Ann. Thorac. Surg., May 1, 2008; 85(5): 1712 - 1718. [Abstract] [Full Text] [PDF]
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P. Lurz, L. Coats, S. Khambadkone, J. Nordmeyer, Y. Boudjemline, S. Schievano, V. Muthurangu, T. Y. Lee, G. Parenzan, G. Derrick, et al. Percutaneous Pulmonary Valve Implantation: Impact of Evolving Technology and Learning Curve on Clinical Outcome Circulation, April 15, 2008; 117(15): 1964 - 1972. [Abstract] [Full Text] [PDF]
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E. Troost, B. Meyns, W. Daenen, F. Van de Werf, M. Gewillig, K. Van Deyk, P. Moons, and W. Budts Homograft survival after tetralogy of Fallot repair: determinants of accelerated homograft degeneration Eur. Heart J., October 2, 2007; 28(20): 2503 - 2509. [Abstract] [Full Text] [PDF]
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T. Miyazaki, M. Yamagishi, A. Nakashima, K. Fukae, T. Nakano, H. Yaku, and H. Kado Expanded polytetrafluoroethylene valved conduit and patch with bulging sinuses in right ventricular outflow tract reconstruction J. Thorac. Cardiovasc. Surg., August 1, 2007; 134(2): 327 - 332. [Abstract] [Full Text] [PDF]
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D. Boethig, H. Goerler, M. Westhoff-Bleck, M. Ono, A. Daiber, A. Haverich, and T. Breymann Evaluation of 188 consecutive homografts implanted in pulmonary position after 20 years, Eur J Cardiothorac Surg, July 1, 2007; 32(1): 133 - 142. [Abstract] [Full Text] [PDF]
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J. W. Brown, M. Ruzmetov, P. Vijay, M. D. Rodefeld, and M. W. Turrentine Right ventricular outflow tract reconstruction with a polytetrafluoroethylene monocusp valve: A twelve-year experience J. Thorac. Cardiovasc. Surg., May 1, 2007; 133(5): 1336 - 1343. [Abstract] [Full Text] [PDF]
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T. Oosterhof, H. W Vliegen, F. J Meijboom, A. H Zwinderman, B. Bouma, and B. J M Mulder Long-term effect of pulmonary valve replacement on QRS duration in patients with corrected tetralogy of Fallot Heart, April 1, 2007; 93(4): 506 - 509. [Abstract] [Full Text] [PDF]
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J. W. Brown, M. Ruzmetov, M. D. Rodefeld, P. Vijay, and R. K. Darragh Valved bovine jugular vein conduits for right ventricular outflow tract reconstruction in children: an attractive alternative to pulmonary homograft. Ann. Thorac. Surg., September 1, 2006; 82(3): 909 - 916. [Abstract] [Full Text] [PDF]
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D. L.S. Morales, B. E. Braud, K. S. Gunter, K. E. Carberry, K. A. Arrington, J. S. Heinle, E. D. McKenzie, and C. D. Fraser Jr Encouraging results for the Contegra conduit in the problematic right ventricle-to-pulmonary artery connection. J. Thorac. Cardiovasc. Surg., September 1, 2006; 132(3): 665 - 671. [Abstract] [Full Text] [PDF]
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R.-E. W. Kavey Optimal Management Strategies for Patients With Complex Congenital Heart Disease Circulation, June 6, 2006; 113(22): 2569 - 2571. [Full Text] [PDF]
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L. F. Peng, D. B. McElhinney, A. W. Nugent, A. J. Powell, A. C. Marshall, E. A. Bacha, and J. E. Lock Endovascular Stenting of Obstructed Right Ventricle-to-Pulmonary Artery Conduits: A 15-Year Experience Circulation, June 6, 2006; 113(22): 2598 - 2605. [Abstract] [Full Text] [PDF]
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T. Oosterhof, F. J. Meijboom, H. W. Vliegen, M. G. Hazekamp, A. H. Zwinderman, B. J. Bouma, A. P.J. van Dijk, and B. J.M. Mulder Long-term follow-up of homograft function after pulmonary valve replacement in patients with tetralogy of Fallot Eur. Heart J., June 2, 2006; 27(12): 1478 - 1484. [Abstract] [Full Text] [PDF]
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