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Association of pulmonary conduit type and size with durability in infants and young children
Jeffrey A Poynter1, Pirooz Eghtesady, Brian W McCrindle
1Division of Cardiac Surgery, The Hospital for Sick Children, Toronto, Ontario; Division of Cardiac Surgery, Indiana University School of Medicine, Indianapolis, Indiana.
Insights
Surgeons can improve the durability of pulmonary artery conduits in children by selecting bovine jugular venous valved conduits (JVVC) and ensuring appropriate sizing. This leads to fewer future surgeries for congenital heart disease patients.
Area of Science:
- Pediatric Cardiac Surgery
- Congenital Heart Disease
- Biomaterials in Medicine
Background:
- Right ventricle to pulmonary artery conduits are used to treat congenital heart disease in infants.
- These conduits often require future surgical replacement.
- Identifying factors influencing conduit durability is crucial for improving patient outcomes.
Purpose of the Study:
- To identify surgeon-modifiable factors affecting the durability of initial right ventricle to pulmonary artery conduits.
- Focus on children under 2 years of age at the time of initial conduit insertion.
- Determine if conduit type and size impact the need for reoperation.
Main Methods:
- Analysis of data from 429 infants undergoing initial conduit insertion across 24 institutions.
- Utilized parametric hazard analysis to assess factors associated with conduit durability.
- Adjusted for patient characteristics, institutional variations, and subsequent interval procedures.
Main Results:
- Conduit durability at a median follow-up of 6.0 years was 63%, with 32% requiring replacement.
- Smaller conduit z-scores were significantly associated with earlier replacement (p = 0.002).
- Bovine jugular venous valved conduits (JVVC) demonstrated superior durability compared to aortic or pulmonary allografts (p = 0.002 and p = 0.03, respectively).
Conclusions:
- Pulmonary conduit type and pre-operative sizing (z-score) are key determinants of long-term conduit durability.
- Surgeons can enhance durability by judiciously oversizing conduits and selecting JVVC.
- These modifications can reduce the frequency of reoperations in pediatric patients with congenital heart disease.
Background:
Treatment of congenital heart disease may include placement of a right ventricle to pulmonary artery conduit that requires future surgical replacement. We sought to identify surgeon-modifiable factors associated with durability (defined as freedom from surgical replacement or explantation) of the initial conduit in children less than 2 years of age at initial insertion.
Methods:
Since 2002, 429 infants were discharged from 24 Congenital Heart Surgeons' Society member institutions after initial conduit insertion. Parametric hazard analysis identified factors associated with conduit durability while adjusting for patient characteristics, the institution where the conduit was inserted, and time-dependent interval procedures performed after conduit insertion but before replacement/explantation.
Results:
In all, 138 conduit replacements (32%) and 3 explantations (1%) were performed. Conduit durability at a median follow-up of 6.0 years (range, 0.1 to 11.7) was 63%. After adjusting for interval procedures and institution, placement of a conduit with smaller z-score was associated with earlier replacement/explantation (p = 0.002). Moreover, conduit durability was substantially reduced with aortic allografts (p = 0.002) and pulmonary allografts (p = 0.03) compared with bovine jugular venous valved conduits (JVVC). The JVVC were 12 mm to 22 mm in diameter at insertion (compared with 6 mm to 20 mm for allografts); therefore, a parametric propensity-adjusted analysis of patients with aortic or pulmonary allografts versus JVVC with diameter of 12 mm or greater was performed, which verified the superior durability of JVVC.
Conclusions:
Pulmonary conduit type and z-score are associated with late conduit durability independent of the effects of institution and subsequent interval procedures. Surgeons can improve long-term conduit durability by judiciously oversizing, and by selecting a JVVC.
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