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Reoperative right ventricular outflow tract conduit reconstruction: risk analyses at follow up
Mark D Rodefeld1, Mark Ruzmetov, Mark W Turrentine
1Section of Cardiothoracic Surgery, James W. Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, Indiana 46202-5123, USA. rodefeld@iupui.edu
Insights
Most right ventricular-to-pulmonary artery (RV-PA) conduits in children require replacement. Reoperation for conduit dysfunction offers survival comparable to primary placement, with low risks.
Area of Science:
- Pediatric Cardiac Surgery
- Congenital Heart Disease Repair
- Vascular Grafting
Background:
- Right ventricular-to-pulmonary artery (RV-PA) conduits are crucial for treating congenital heart defects in children.
- These conduits often necessitate future reoperation due to expected dysfunction and failure.
Purpose of the Study:
- To review institutional experience with conduit right ventricular outflow tract (RVOT) reconstruction.
- To assess the frequency of conduit replacement and identify risk factors for conduit dysfunction and failure.
Main Methods:
- A retrospective review of 261 pediatric patients undergoing primary RV-PA conduit implantation between 1980 and 2007.
- Comparison of primary operation and reoperation groups regarding mortality, interventions, and explant rates.
- Multivariate analysis to identify risk factors for conduit failure.
Main Results:
- Conduit replacement was required in 35% of patients, with a mean time of 6 years post-implantation.
- Significant risk factors for conduit replacement included small allograft diameter and diagnosis of truncus arteriosus.
- Diagnosis of truncus arteriosus and surgery before 1992 were independent predictors of mortality.
Conclusions:
- The majority of RVOT conduits implanted in children will eventually require replacement.
- Reoperative RVOT reconstruction is feasible, demonstrating survival rates comparable to primary conduit placement.
- Reoperation for conduit failure in pediatric patients can be performed with low morbidity and mortality.
Background And Aim Of The Study:
Right ventricular-to-pulmonary artery (RV-PA) conduits are implanted in the right ventricular outflow tract (RVOT) of children, with the knowledge that future reoperation will likely be required. The authors' experience of conduit RVOT reconstruction was reviewed in order to assess the frequency of conduit replacement and to determine risk factors for conduit dysfunction and failure.
Methods:
Between January 1980 and April 2007, a total of 261 patients (mean age 8.7 +/- 11.7 years) underwent primary RVOT reconstruction with an RV-PA conduit at the authors' institution. There were 19 (7%) early deaths. Among the survivors, 84 (35%) underwent conduit explant at the implanting hospital with insertion of a second conduit at a mean of 6.0 +/- 3.7 years (range: 7 months to 22 years) after the first implantation. The primary operation and reoperation patient groups were compared with regard to the incidence of early death, late death, conduit-related intervention without explant, and conduit explant.
Results:
Six risk factors for mortality were significant on univariate analyses: surgery before 1992 (p = 0.005), age <3 months (p = 0.001), diagnosis of truncus arteriosus (p <0.001), reconstruction with allografts (p = 0.05), association with interrupted aortic arch (p = 0.05) and with truncal valve insufficiency (p = 0.05). Of these six factors, only the diagnosis of truncus arteriosus (p = 0.001) and surgery before 1992 (p = 0.05) remained significant by multivariate analysis. Univariable analysis was performed for multiple factors, of which the following were found to be significant: body weight (p <0.003), age (p = 0.002), conduit diameter (p <0.0001), conduit type (p = 0.006), and diagnosis of truncus arteriosus (p <0.0001). Multivariable analysis of significant univariable risks revealed small allograft diameter (p <0.001) and diagnosis of truncus arteriosus (p <0.001) to be significant risk-factors for need of replacement.
Conclusion:
Most RVOT conduits placed in children will eventually require replacement. Patient survival for conduit replacement is comparable to that for primary conduit placement. Reoperative conduit RVOT reconstruction is possible, with low morbidity and mortality.
