Valved bovine jugular vein conduits for right ventricular outflow tract reconstruction in children: an attractive alternative to pulmonary homograft

Abstract

Background: Pulmonary homografts (PH) have been the preferred valved conduits for right ventricular outflow tract (RVOT) reconstruction in the US since the mid-1980s. Although PHs have worked well for Ross patients, many PH extracardiac conduits used for congenital heart surgery suffer from degeneration and develop regurgitation and obstruction within months after implantation and require replacement within 4 to 6 years. Recently a valve-containing bovine jugular vein (Contegra, Medtronic, Inc, Minneapolis, MN) was introduced for clinical trials for a variety of patients requiring RVOT reconstruction.

Methods: The early results of RVOT reconstruction utilizing the Contegra conduit were retrospectively analyzed in 62 patients. This series consisted of 9 newborns with truncus arteriosus, 39 patients with failed PHs, 6 with pulmonary atresia and 2 with tetralogy of Fallot with absent pulmonary valve, 2 with transposition of great arteries with ventricular septal defect and pulmonary stenosis, and 4 undergoing a Ross procedure. The patients ages ranged from 2 weeks to 18 years (mean, 7.3 +/- 6.0 years) and weights were from 2 to 83 kg (mean, 28.1 +/- 22.3 kg). The Contegra conduit sizes varied in diameter between 12 and 22 mm (mean, 18.2 +/- 4.1 mm).

Results: There were two early (3%) and four (7%) late deaths and none of them was conduit related. There has been one conduit explantation, and seven patients have required reinterventions to relieve stenosis at or beyond the distal anastomosis of the conduit to pulmonary artery bifurcation (8 of 60; 13%). Six of the 7 patients had balloon dilatation of the branch pulmonary arteries for preexisting stenosis. One patient developed distal anastomotic stenosis that did not yield to balloon angioplasty and she underwent surgical patch arterioplasty of the distal anastomosis. The interval from conduit implantation to reintervention ranged from 3 to 27 months (mean, 11.1 +/- 7.8 months). Of these, three patients required placement of a stent in the left (n = 1) or both branch pulmonary arteries (n = 2). During the short to intermediate follow-up in our series we have not observed, on echocardiography, shrinkage of the Contegra as we and others have reported with PHs.

Conclusions: The Contegra conduit offers a promising alternative for RVOT reconstruction. Early hemodynamic performance compares favorably with PHs. Clinical advantages are greater availability in sizes from 12 to 22 mm and natural continuity between the valve and conduit that allows proximal infundibular shaping without additional materials. The price of the bovine jugular venous valve is approximately one-half that of many PHs in the US. Short-term freedom from dysfunction is at least as good as PHs. Long-term durability must be determined for this new conduit. The Contegra conduit is currently our conduit of choice for RVOT reconstruction in infants, children, and young adults.