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Published on: July 23, 2014
Allograft degeneration in infant pulmonary valve allograft recipients
1Department of Cardiothoracic Surgery, Childrens Hospital, University of Colorado Health Sciences Center, Denver, 80218.
Insights
Infants undergoing right ventricular outflow tract (RVOT) reconstruction with pulmonary valve allografts face higher failure rates. Early allograft failure in infants may be immunologic, suggesting alternatives for this age group.
Area of Science:
- Cardiovascular Surgery
- Pediatric Cardiology
- Immunology
Background:
- Pulmonary valve allografts are used for right ventricular outflow tract (RVOT) reconstruction in pediatric patients.
- Infants undergoing RVOT reconstruction with allografts experience higher rates of fibrocalcification and valvar insufficiency compared to older children.
Purpose of the Study:
- To evaluate the outcomes of cryopreserved pulmonary valve allografts in pediatric patients undergoing RVOT reconstruction.
- To compare the incidence of allograft failure between infants and older children.
Main Methods:
- Retrospective analysis of 137 pediatric patients who received a cryopreserved pulmonary valve allograft for RVOT repair since 1985.
- Patients were divided into two groups: those 1 year or older and those younger than 1 year at operation.
- Clinical follow-up data, including mortality, reoperation, and allograft explantation, were analyzed.
Main Results:
- Infants (younger than 1 year) had a significantly higher hospital mortality rate (25%) and late mortality/allograft explantation rate (22%) compared to older children (10% hospital mortality, 5% late mortality/reoperation).
- The primary indication for reoperation or explantation in both groups was allograft fibrocalcification and valvar insufficiency.
- Early allograft failure in infants may have an immunologic basis.
Conclusions:
- Cryopreserved pulmonary valve allografts demonstrate a higher failure rate in infants compared to older children undergoing RVOT reconstruction.
- The potential immunologic etiology of early allograft failure in infants warrants consideration of alternative strategies.
- Nonviable allografts or low-dose cyclosporine may be viable alternatives for RVOT reconstruction in infants.
Abstract:
Infants who have undergone pulmonary valve allograft reconstruction of their right ventricular outflow tract (RVOT), experience an increased incidence of allograft fibrocalcification and valvar insufficiency, compared to older children. Since 1985, 137 pediatric patients have received a cryopreserved pulmonary valve allograft to repair their RVOT. One hundred and five patients were 1 year of age or more and 32 were younger than 1 year at operation. In the former group, there were 11 hospital deaths (10%). Ninety-four operative survivors have been followed clinically for one month to 7.2 years (mean: 3.4 years). One patient required cardiac transplant secondary to myocardial dysfunction. There have been three late deaths (3%), and two children (2%) have undergone reoperation to replace the allograft. In the infant group, there were eight hospital deaths (25%). During 1 month to 6.8 years (mean: 2.2 years) of clinical follow up, there have been six late deaths (25%), and four children (22%) have required allograft explant. The most common indication for reoperation has been allograft fibrocalcification and valvar insufficiency. The relatively high incidence of early allograft failure in infants, which may have an immunologic etiology, has prompted consideration of nonviable allografts or low dose cyclosporine as alternatives when surgical reconstruction of the RVOT is required in children younger than 1 year of age.
