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Ann Thorac Surg 2008;86:2026-2027. doi:10.1016/j.athoracsur.2008.04.052
© 2008 The Society of Thoracic Surgeons
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Correspondence

Unexpected Early Failure of a Decellularized Right Ventricle to Pulmonary Artery Graft

Christian Schreiber, MD, PhDa, Andreas Eicken, MD, PhDb, Stefan Seidl, MDc, Rüdiger Lange, MD, PhDd

a Clinic for Cardiovascular Surgery, German Heart Center Munich at the Technical University Munich, Lazarettstrasse 36, Munich, 80636 Germany
b Department of Pediatric Cardiology and Congenital Heart Disease, German Heart Center Munich at the Technical University Munich, Lazarettstrasse 36, Munich, 80636 Germany
c Department of Pathology, Technical University Munich, Ismaningerstrasse 22, Munich, 81675 Germany
d Clinic for Cardiovascular Surgery, German Heart Center Munich at the Technical University Munich, Lazarettstrasse 36, Munich, 80636 Germany

(Email: schreiber{at}dhm.mhn.de; eicken{at}dhm.mhn.de; stefan.seidl{at}lrz.tu-muenchen.de; lange{at}dhm.mhn.de).

To the Editor:

Stimulated by the recently published results on mid-term clinical results of a tissue-engineered heart valve [1], we equally began to use the graft. However, we wish to report on a 20-year-old patient who needed an early reoperation. Primarily, a 30-mm, tissue-engineered heart valve was implanted. The patient had previous Fallot repair. At discharge, no gradient was measured across the right ventricular outflow tract. Already, after 6 months, the noninvasive peak systolic Doppler gradient measured 50 mm Hg across the prosthesis. Upon catheterization after 8 months the gradient was 57 mm Hg. The right ventricular end-diastolic volume, which had initially fallen to 120 mL/m2, was then at 188 mL/m2. At the site of the graft, a distinct stenosis was confirmed. Ten months after the initial operation, the tissue-engineered heart valve had to be replaced with a homograft. Macroscopic evaluation showed a narrowing throughout the conduit (Fig 1). A cross section taken at the valvular level histologically showed a lympho-histiocytic infiltrate with focal foreign-body reaction with giant cells and massive pseudo-intimal proliferation. Also, the valves were involved with focal infiltration of lymphocytes, histiocytes, and granulocytes (Fig 1).


Figure 1
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  		Fig 1. (A, B) Right heart angiography depicting significant narrowing at the sight of the implanted valve. (C) Inflammation of the valves with focal granulocytic infiltration (H&E stain, x100). (D) Higher magnification with giant cells of the foreign-body type (arrows) (H&E stain, x200). (E) Microscopic image showing the pseudo-intimal proliferation (between arrows) (H&E stain, x12.5).

 
Dohmen and co-workers [1] have not had a similar patient or conduit failure, respectively. However, our observed case, and especially the massive pseudo-intimal peel formation and chronic inflammation with foreign-body reaction remind us of what we described earlier [2]. Graft conservation may have contributed to delayed endothelialization and increased thrombogenicity of the graft surface. In addition, a nonspecific foreign-body type reaction may have occurred. It is of note that they described another patient collective (Ross patients). Further observations on other patient cohorts will help provide more detailed understanding of the tissue-engineered heart valve.


   References
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 References
 

  1. Dohmen PM, Lembcke A, Holinski S, et al. Mid-term clinical results using a tissue-engineered pulmonary valve to reconstruct the right ventricular outflow tract during the Ross procedure Ann Thorac Surg 2007;84:729-736.[Abstract/Free Full Text]
  2. Schreiber C, Sassen S, Kostolny M, et al. Early graft failure of small-sized porcine valved conduits in reconstruction of the right ventricular outflow tract Ann Thorac Surg 2006;82:179-185.[Abstract/Free Full Text]

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Pascal Dohmen and Wolfgang Konertz
Ann. Thorac. Surg. 2008 86: 2027-2028. [Extract] [Full Text] [PDF]



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Ann. Thorac. Surg., December 1, 2008; 86(6): 2027 - 2028.
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