Right Ventricle to Pulmonary Artery Conduit Augmentation Compared With Replacement in Young.. Augmentation was less often performed in patients with an aortic homograft and by one surgeon. At conduit 2, cardiopulmonary bypass time was longer in replacement patients (1. Early mortality was 0. Aggressive Patch Augmentation May Reduce Growth Potential of Hypoplastic Branch Pulmonary Arteries After Tetralogy of Fallot Repair. Pulmonary Artery/abnormalities*. We obtained good results in the right heart bypass operation concomitant with the pulmonary arterial augmentation using the vena cava in 7 patients. Comparison of Extracellular Matrix Patch and Standard Patch Material in the Pulmonary Arteries. After pulmonary artery (PA) patch augmentation, surgical or. Stem Cell–Derived, Tissue-Engineered Pulmonary Artery Augmentation Patches In Vivo. For Congenital Heart Disease. LPA left pulmonary artery. ![]() Freedom from reoperation was 8. Aortic homograft as a first conduit was associated with shorter freedom from reoperation. Successful Hybrid Rescue of Occluded Pulmonary Artery in Pulmonary. Patch angioplasty of the pulmonary artery may be. Pulmonary artery augmentation with autologous aortic tissue Zohair Al-Halees *, Ganga. Pulmonary Artery Aneurysm Joseph Junewick, MD FACR 02/20/2010 History Child with congenital heart disease. Diagnosis Pulmonary Artery Aneurysm Additional Clinical. Pulmonary atresia is a congenital malformation of the. The pulmonary valve is located on the right side of the heart between the right ventricle and pulmonary artery. Limiting analysis to conduits that were replaced at conduit 2, undersized conduits were associated with shorter freedom from reoperation and smaller body surface area, and undersized conduits were associated with shorter freedom from reintervention. Conclusions. Freedom from a second conduit reoperation after a first conduit replacement was shorter in smaller children and undersized conduits. Conduit augmentation offers similar clinical outcomes in selected patients. Children with many forms of congenital heart disease undergo biventricular repair with a right ventricle to pulmonary artery (RV- PA) conduit. ![]() However, evidence- based decisions about conduit reintervention are difficult to formulate due to the nebulous outcome literature and long- term nature of many important outcomes. Children undergoing biventricular repair with RV- PA conduits present unique problems related to optimizing for small, but growing, chest size, conduit- branch PA size mismatch, and RV incision size. In children, reintervention on dysfunctional conduits is primarily aimed at relieving conduit stenosis, because the consequences of conduit regurgitation are often well tolerated until young adulthood. Freedom from conduit reoperation in mixed cohorts can range anywhere from 6. Therefore, young infants receiving conduits for initial palliation may require multiple reoperations. Factors previously identified to predict conduit longevity include patient age, primary anatomic diagnosis, type of conduit, conduit size, conduit diameter Z- score (standard deviations above or below average pulmonary valve size relative to body surface area), distal PA stenosis, and higher RV systolic pressure . In certain settings, the cost of multiple reoperations and conduit availability are prohibitive. In examining the literature, most reports on conduit longevity focus only on infants or combine primary operations with reoperation and include patients of various ages and with various conduit types. ![]() ![]() With so many variables, it is difficult to assess the effect of different management strategies on outcomes. Studies that stratify analysis by patient age and reoperative status may help minimize the confounding effects of these variables and help inform decisions on specific populations. Patch augmentation of RV- PA conduits is an alternative to complete conduit replacement for the treatment of conduit obstruction. Using readily available autologous, xenograft, or synthetic materials, patches can be crafted to relieve conduit obstruction with the possibility of a more straightforward operative and postoperative course, albeit at the cost of conduit regurgitation. The longevity of augmented conduits relative to replaced conduits is not well described. In this study of young children undergoing a first conduit reoperation (ie, a second conduit operation, conduit 2), we hypothesized that although operative and perioperative outcomes such as duration of cardiopulmonary bypass and intensive care unit stay would be shorter for patients undergoing conduit augmentation at the time of conduit 2, compared with those undergoing conduit replacement, freedom from further reoperation (conduit 3) or reintervention after conduit augmentation would be shorter. The primary hypothesis was that freedom from conduit 3 was significantly shorter after conduit augmentation compared with conduit replacement. Material and Methods. The Children’s Hospital Boston Cardiovascular Program database was queried for patients 1. RV- PA conduit that was placed during the initial complete repair. We limited the study to patients 1. Patients in whom the first conduit was placed without complete repair (eg, ventricular septal defect left open in patients with tetralogy of Fallot and pulmonary atresia) were excluded. Baseline demographic, anatomic, and hemodynamic data before conduit 2 as well as operative details of conduit 2 were collected. Cross- sectional follow- up was obtained, and data on survival, transplant, conduit reoperation, conduit dilation or stenting, and hemodynamics were recorded. This retrospective chart review was approved by departmental and institutional review boards, and a waiver of patient consent was granted. Surgical Procedure. The conduit augmentation procedure generally consisted of a longitudinal incision along the entire length of the anterior portion of the RV- PA conduit across both RV and PA anatomoses, although there was variation in the extent of the incision. The homograft valve was often excised. An onlay patch was crafted from expanded polytetrafluoroethylene, polyethylene terephthalate fiber (Dacron), or homograft for each patient and sewn into this incision, thereby increasing the diameter. The size of the patch was not standardized. Data Analysis. The primary outcome was freedom from conduit 3 after conduit 2. Secondary outcomes included survival and a composite outcome of freedom from conduit 3 or conduit dilation (freedom from conduit reintervention) after conduit 2. We also analyzed demographic, anatomic, and procedural factors including age at original conduit operation, original conduit type, original conduit size, original conduit Z- score (based on previously published normative echocardiographic data . Baseline variables were compared using Student’s t test or . Primary and secondary outcomes were analyzed using Kaplan- Meier analysis and multivariable Cox regression analysis. Multivariate models were constructed using independent variables with significance levels up to a probability value of 0. Outcome analyses were also performed with adjustment for age and surgeon at conduit 2. Data are presented as mean . Baseline variables are compared in Table 1. Conduit augmentation was less likely to be performed when the original conduit was an aortic homograft compared with other conduits (Table 1). At the time of conduit 2, there were no differences in the severity of conduit obstruction between patients whose original conduit was a pulmonic homograft (6. At the time of conduit 2, there were no differences between patients who underwent replacement and those who underwent augmentation with respect to age, body surface area, echocardiogram- derived maximum instantaneous gradient across the conduit, catheterization- derived conduit peak systolic ejection gradient, or proportion of patients who underwent conduit dilation or stenting before conduit 2. Baseline Variables Before Conduit 2. Conduit 2 Indications and Procedures. Overall, conduit stenosis was an indication for conduit 2 in 1. The patient without conduit stenosis was 1 of 1. Additional indications for conduit 2 in patients with conduit obstruction included subacute bacterial endocarditis attributable to an infected conduit in 1, an echocardiographic mass in the RV outflow tract that was discovered intraoperatively to be an RV muscle bundle in 1, and 1 patient in whom the origin of the right PA was covered by a stent. Residual ventricular septal defects were present in 1. There was no difference in age at conduit 2. Original conduits were slightly larger in the replacement group (1. The mean nominal conduit diameter was 1. Among patients undergoing conduit augmentation at conduit 2, patch material included expanded polytetrafluoroethylene in 1. Dacron in 9, and homograft tissue in 7. Patch size and configuration, as well as procedures to tailor the PA bifurcation, depended on the surgeon and specific case, and the completed diameter of the augmented conduit was not routinely measured. Among the 5 surgeons responsible for these 1. Perioperative Outcomes. All conduit 2 patients underwent surgery with cardiopulmonary bypass and recovered in the cardiac intensive care unit. Total pump time was significantly longer in patients who underwent conduit replacement compared with augmentation (1. There was no difference in length of cardiac intensive care unit stay between patients who underwent replacement (2. There was 1 early death (. Median follow- up duration was 7. Including the early death, 1. Overall survival by Kaplan- Meier analysis was 9. Figure 1. Overall survival after conduit 2. Conduit Reoperation After Conduit 2. During follow- up after conduit 2, 7. Reoperations were performed primarily for conduit stenosis, and overall no differences were found between replacement and augmentation groups in indications for conduit 3 (Table 2). In the replacement group, 5 patients underwent closure of a residual ventricular septal defect, and 3 had tricuspid valve repair whereas none in the augmentation group underwent additional procedures. Conduit Reintervention After Conduit 2. By Kaplan- Meier analysis, overall freedom from conduit 3 after conduit 2 was 9. As depicted in Figure 2, there was a trend toward shorter freedom from conduit reoperation in the replacement group compared with the augmentation group (log rank p = 0. On multivariable Cox regression analysis, the use of an aortic homograft as the original conduit was associated with shorter freedom from reoperation after conduit 2 (. No other independent variable analyzed was associated with freedom from conduit 3. This result was unaffected by controlling for surgeon. Freedom from conduit reoperation after conduit 2 stratified by conduit augmentation versus conduit replacement. Limiting analysis to the conduit replacement group and controlling for surgeon, factors associated with shorter freedom from conduit 3 by univariate Cox regression included smaller conduit size and Z- score, and an aortic homograft as the original conduit.
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