Ann Thorac Surg 2007;83:682-684
© 2007 The Society of Thoracic Surgeons
Case Reports
Aneurysmal Dilatation of the Contegra Bovine Jugular Vein Conduit After Reconstruction of the Right Ventricular Outflow Tract
Eva Maria Delmo-Walter, MDa,*,
Vladimir Alexi-Meskishvili, MD, PhDa,
Hashim Abdul-Khaliq, MD, PhDb,
Rudolf Meyer, MD, PhDc,
Roland Hetzer, MD, PhDa
a Department of Cardiovascular and Thoracic Surgery, Deutsches Herzzentrum Berlin, Germany
b Department of Pediatric Cardiology and Congenital Heart Diseases, Deutsches Herzzentrum Berlin, Germany
c Department of Pathology, Deutsches Herzzentrum Berlin, Germany, Deutsches Herzzentrum Berlin, Germany
Accepted for publication June 19, 2006.
* Address correspondence to Dr Delmo-Walter, Deutsches Herzzentrum Berlin, Augustenburger Platz 1, 10353 Berlin. (Email: delmo-walter{at}dhzb.de).
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Abstract
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An aneurysm of a 14-mm Contegra bovine conduit 5 years after a total repair of tetralogy of Fallot was confirmed by echocardiography, angiography, and magnetic resonance tomography. The conduit was replaced. Histologic examination of the explanted conduit revealed an acellular homogenous material with occasional elastic fibers, fragile, diffuse and complex collagenization throughout the conduit and mild foreign body reaction. Pannus formed over the top of all commissures and on the conduit wall, with extensive mineralization. Close follow-up is seen as mandatory for early detection of the bovine vein conduit aneurysm, particularly in patients in whom small-sized conduits are implanted.
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Introduction
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Surgical correction of a variety of congenital right ventricular outflow tract anomalies requires interposition of a valved conduit to reestablish continuity between the right ventricle and the pulmonary artery bifurcation. Use of bovine jugular vein conduit remains an alternative choice in these cases. It has gained widespread acceptance and increased enthusiasm among congenital heart surgeons.
A 13-month-old boy underwent a complete repair of tetralogy of Fallot, including closure of the ventricular septal defect and placement of a 14-mm Contegra conduit (Medtronic Inc, Minneapolis, MN) between the right ventricle and the pulmonary artery (Fig 1). His postoperative course was uneventful, and subsequent regular follow-up examinations within a period of 5 years showed an active boy with a normal developmental growth pattern.
In the fifth postoperative year, however, a routine chest roentgenogram showed a right ventricular dilatation. Sequential echocardiography showed enlargement of the right ventricle and progressive increase of right ventricular pressure up to 70 mm Hg. Cardiac catheterization confirmed systemic right ventricular pressure and a stenosis at the supravalvular area with a gradient of 60 mm Hg. A right ventricular angiogram showed an 18-mm aneurysmal dilatation of the conduit extending from the ventricular anastomosis (Fig 2). Magnetic resonance imaging (MRI) confirmed angiographic findings. The patient underwent conduit replacement with a 15-mm homograft. Postoperative course was unremarkable.
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Fig 2. Right ventricular angiography showing supravalvular stenosis (arrow) and an aneurysmal dilatation of the conduit extending from the ventricular anastomosis(asterisk) to the distal anastomosis with pulmonary bifurcation.
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Macroscopic examination of the explanted Contegra valved conduit revealed flexible leaflets, with a large tear in one leaflet (Fig 3A and B). The commissures appeared to be intact. Pannus had grown over the tops of all commissures (Fig 3C). A glistening white pannus was present on the outflow of the conduit covering the tops of all commissures and significantly reducing the outflow orifice area (Fig 3D). Radiographic analysis showed extensive partial mineralization in the conduit wall extending slightly behind one leaflet.
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Fig 3. (A and B) Extensive mineralization in the right side of the conduit wall. (C and D) Pannus developed on the distal anastomosis significantly reduced effective outflow orifice area.
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Histology revealed a homogenous almost acellular conduit wall with several elastic fibers, new vascular network, and collagenization throughout the conduit. Inflammatory tissues reaction was also present at the outside layer (Fig 4).
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Fig 4. Photomicrograph showing homogenous almost acellular conduit wall with several elastic fibers, new vascular network, collagenization throughout the conduit, and inflammatory tissues reaction at the outside layer. (H&E stain, magnification 250x.)
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Comment
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Aneurysmal dilatation of nonsupported Contegra conduit has rarely been reported and usually is explained with increased pressure in the right ventricle [1]. In our patient, proximal as well as distal aneurysmal dilatation of the conduit was observed, presumably as a result of the stenosis of the distal anastomosis caused by pannus formation and increasing stress of the wall of the conduit. A pathologic intimal proliferation predominantly located at the area of the pulmonary anastomosis explains the pulmonary obstruction. Mechanisms involved are not completely understood, but geometric distortion along with immunologic rejection has been suggested [2, 3]. Close follow-up seems mandatory for early detection of the bovine vein conduit aneurysm, particularly in patients in whom small size conduits were implanted.
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Acknowledgments
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We thank Anne M. Gale, Editor in the Life Sciences, for editorial assistance.
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References
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- Tiete AR, Sachweh JS, Roemer U, Kozlik-Feldmann R, Reichart B, Daebritz S. Right ventricular outflow tract reconstruction with the Contegra bovine jugular vein conduit: a word of caution Ann Thorac Surg 2004;77:2151-2156.[Abstract/Free Full Text]
- Boudjemline Y, Bonnet D, Massih TA, 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]
- Kadner A, Dave H, Stallmach T, Turina M, Pretre R. Formation of a stenotic fibrotic membrane at the distal anastomosis of bovine jugular vein grafts (Contegra) after right ventricular outflow tract reconstruction J Thorac Cardiovasc Surg 2004;127:285-286.[Free Full Text]
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Abstract
Introduction
