Outcomes Following Heterotopic Placement of Right Ventricle to Pulmonary Artery Conduits

Abstract

Background: 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. Methods: 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. Results: 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. Conclusions: 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.

Does heterotopically-placed right ventricle-to-pulmonary artery (RV-to-PA) conduit negatively affect its longevity, reintervention-free survival, and overall survival? Our experience.

“…Even though our results did not show pulmonary homograft to be superior in terms of conduit dysfunction-free, reintervention-free, and overall survival, we still preferred pulmonary homograft to be the conduit of choice at our institution. One study 12 mentioned that immune process had a more prominent role in causing conduit dysfunction in children than in adults. However, from our results, we found that younger age at operation did not adversely affect conduit longevity, reintervention-free survival, and overall survival.…”

“…However, the nal results varied widely, and de nite risk factors or determinants of conduit longevity, reintervention-free survival, and overall survival still could not be precisely de ned. Furthermore, not only conduit position but also conduit types and sizes could impact their durability and patient's reintervention-free and overall survival 5,8,9,[12][13][14][16][17][18] . However, most of the results contradicted each other, with no clear consensus made.…”

Pediatric pulmonary valve replacements: Clinical challenges and emerging technologies

“…No commercially available PPVRs are ideal and RVOT reconstruction will often require repeat operations later in life to replace dysfunctional prosthetics 18,19 . Importantly, freedom from RVOT reoperation varies depending on the clinical context, influenced by factors such as CHD etiology, age at implantation and PPVR type, as well as institutional and patient preferences.…”

“…Many CHDs affect the right ventricular outflow tract (RVOT) (Table 1), leading to a significant requirement for pulmonary valve (PV) replacement in the pediatric population 12–15 . The PV is one of four heart valves that mediate a strict unidirectional blood flow through the heart 16,17 ; however, the lack of ideal replacement prosthetics generates a requirement for repeat interventions throughout early life 18,19 . Prosthetics based on metals are prone to thrombosis and require lifelong anticoagulation, introducing additional burdens that persist past childhood, 20,21 while those based on biological materials exhibit underwhelming durability due to their immunogenicity and structural degradation 22,23 .…”

From Scan to Simulation—A Novel Workflow for Developing Bioinspired Heart Valves

“…Bioprostheses and homografts are susceptible to immune responses and structural valve deterioration [3]. Unfortunately, these poor outcomes tend to manifest earlier for younger patients, forcing them to undergo multiple operations throughout their lifetime [4][5][6].…”