Risk factors for early reintervention in patients with cryopreserved homografts in the pulmonary position

Cryopreserved homograft implantation in the pulmonary position is a common surgical approach for pulmonary valve replacement, although it carries a risk of early failure requiring reintervention. This study aimed to identify clinical, anatomical, surgical, graft, and postoperative factors associated with early failure, defined as reintervention (percutaneous or surgical) within 3 years.

In this retrospective cohort study (2017-2024), we included 136 patients (median weight 45.0 [IQR: 25.25-60.00] kg; age 14.11 [8.31-18.09] years) who received a homograft in the pulmonary position. Time-to-event analyses were performed to identify factors associated with early failure, including multivariable Cox proportional hazards regression.

The most frequent underlying conditions were tetralogy of Fallot in 44.0% and common arterial trunk in 16.9%. The median homograft size was 22 [19-24] mm, and 15 (11%) were aortic homografts. The median follow-up was 4.15 [1.61-5.00] years. Eighteen patients (13.2%) required reintervention at a median of 1.29 [0.72-1.93] years. Reasons for reintervention included postimplantation due to stenosis (n=8), stenosis and infective endocarditis (n=1), and stenosis and regurgitation (n=9). Interventions included percutaneous pulmonary valve implantation (n=5), homograft dilatation (n=3), stenting (n=3), and surgical replacement or heterograft implantation (n=7). Univariate analysis identified significant associations with fever, fever without documented infection, pericardial/mediastinal collection necessitating reintervention, and elevated RVOT velocity on echo (> 2.1 m/s) at discharge. On multivariable Cox regression analysis, fever without documented infection remained independently associated with earlier reintervention (HR, 4.42; 95%CI, 1.34-14.52; P=.014).

Early reintervention is associated with postoperative inflammatory markers and immediate suboptimal homograft function. These findings support and refine previous observations on early homograft dysfunction and may help identify patients who warrant closer postoperative surveillance.