Long-Term Comparison Between Pulmonary Homograft Versus Bioprosthesis for Pulmonary Valve Replacement in Tetralogy of Fallot

Abstract

Background Tetralogy of Fallot repair results in late occurrence of pulmonary regurgitation, which requires pulmonary valve replacement in a large proportion of patients. Both homografts and bioprostheses are used for pulmonary valve replacement as uncertainty remains on which prosthesis should be considered superior. We performed a long-term imaging and clinical comparison between these 2 strategies. Methods and Results We compared echocardiographic and clinical follow-up data of 209 patients with previous tetralogy of Fallot repair who underwent pulmonary valve replacement with homograft (n=75) or bioprosthesis (n=134) between 1995 and 2018 at a tertiary hospital. The primary end point was the composite of pulmonary valve replacement reintervention and structural valve deterioration, defined as a transpulmonary pressure decrease ≥50 mm Hg or pulmonary regurgitation degree of ≥2. Mixed linear model and Cox regression model were used for comparisons. Echocardiographic follow-up duration was longer in the homograft group (8 [interquartile range, 4-12] versus 4 [interquartile range, 3-6] years; P<0.001). At the latest echocardiographic follow-up, homografts showed a significantly lower transpulmonary systolic pressure decrease (16 [interquartile range, 12-25] mm Hg) when compared with bioprostheses (28 [interquartile range, 18-41] mm Hg; mixed model P<0.001) and a similar degree of pulmonary regurgitation (degree 0-4) (1 [interquartile range, 0-2] versus 2 [interquartile range, 0-2]; mixed model P=0.19). At 9 years, freedom from structural valve deterioration and reintervention was 81.6% (95% CI, 71.5%-91.6%) versus 43.4% (95% CI, 23.6%-63.2%) in the homograft and bioprosthesis groups, respectively (adjusted hazard ratio, 0.27; 95% CI, 0.13-0.55; P<0.001). Conclusions When compared with bioprostheses, pulmonary homografts were associated lower transvalvular gradient during follow-up and were associated with a significantly lower risk of reintervention or structural valve degeneration.

Keywords: bioprosthesis; homograft; pulmonary heart disease; regurgitation; structural valve degeneration; tetralogy of Fallot.

Figure 1

Number of bioprostheses and homografts per year.

Figure 2

Postoperative changes in transpulmonary systolic pressure decrease (left) and pulmonary valve regurgitation degree (right) at echocardiographic examinations in patients treated with homografts and with bioprotheses.

Figure 3

Freedom from structural valve deterioration (SVD)/reintervention in patients treated with homografts and with bioprotheses.

Figure 4

Postoperative changes in right ventricle (RV) end‐diastolic (left) and end‐systolic (right) volume at cardiac magnetic resonance imaging examinations in patients treated with homografts and with bioprotheses.