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Replacement of obstructed right ventricular-pulmonary arterial valved conduits with nonvalved conduits in children
Insights
Replacing obstructed valved conduits with nonvalved conduits in children with congenital heart defects significantly reduces right ventricular pressure and gradient. This approach shows excellent early results, potentially decreasing the need for future reoperations.
Area of Science:
- Cardiovascular Surgery
- Pediatric Cardiology
- Congenital Heart Disease
Background:
- Right ventricular-to-pulmonary arterial (RV-PA) valved conduits in children have a high failure rate (6-30%) within 5 years.
- Experience with tetralogy of Fallot repair suggests pulmonary valve competence is not essential for good long-term outcomes.
Purpose of the Study:
- To evaluate the efficacy of replacing obstructed RV-PA valved conduits with nonvalved conduits in pediatric patients.
- To assess the impact on right ventricular systolic pressure and conduit gradient.
Main Methods:
- Retrospective analysis of 26 pediatric patients (12.5 +/- 3.3 years) undergoing conduit replacement.
- Replacement materials included Dacron grafts, pericardium, dura mater, or Dacron patches.
- Pre- and post-operative hemodynamic measurements were recorded.
Main Results:
- Mean right ventricular systolic pressure decreased from 90.5 +/- 20 mm Hg to 45.2 +/- 10.8 mm Hg (p < .001).
- Mean conduit gradient reduced from 67.9 +/- 24.5 mm Hg to 8.9 +/- 7.6 mm Hg (p < .001).
- No operative deaths occurred; all patients were in NYHA class I or II at follow-up (19.5 +/- 14.9 months).
Conclusions:
- Replacement of obstructed RV-PA conduits with nonvalved conduits yields excellent early results in selected pediatric patients.
- This strategy may reduce the need for late reoperations in the absence of pulmonary hypertension or significant ventricular dysfunction.
Abstract:
Six to thirty percent of right ventricular-to-pulmonary arterial (RV-PA) valved conduits in children fail within 5 years. Experience with correction of tetralogy of Fallot has shown that a competent pulmonary valve is not essential for excellent late results in most patients. Between March 1980 and November 1984, 26 patients who were 12.5 +/- 3.3 years old underwent conduit replacement 6.7 +/- 2.4 years after definitive repair of congenital heart defects in which a xenograft RV-PA valved conduit had been used. A new Dacron tube graft (n = 15) or pericardial (n = 8), dura mater (n = 2), or Dacron patch (n = 1) over the previous conduit bed was used as replacement. Preoperative mean right ventricular systolic pressure was 90.5 +/- 20 mm Hg and mean gradient across the conduit was 67.9 +/- 24.5 mm Hg. After replacement with a nonvalved conduit, right ventricular systolic pressure was reduced to 45.2 +/- 10.8 mm Hg (p less than .001), with a gradient of 8.9 +/- 7.6 mm Hg (p less than .001). There were no operative deaths. Follow-up at 19.5 +/- 14.9 months (range = 0 to 53) showed that all patients were in New York Heart Association class I (n = 21) or class II (n = 5). In the absence of pulmonary hypertension, hypoplastic pulmonary arteries, significant right ventricular dysfunction, or unrepaired tricuspid regurgitation, replacement of an obstructed conduit with a nonvalved conduit gives excellent early results and may diminish the need for late reoperation.