Bicuspid homograft reconstruction of the right ventricular outflow tract in infants

The use of homograft tissue in cardiac surgery has progressively increased so that supply is limited, especially in the sizes required for neonatal and infant cardiac operations.

We developed in recent years a technique for surgically reducing the size of more readily available large-diameter homografts, making them suitable for right ventricular outflow tract reconstruction in small infants. This is achieved by means of a longitudinal incision of the oversized conduit, excision of one homograft cusp, and oversewing of the "bicuspid" homograft wrapped around a dilator of appropriate size. Five patients (2 male, 3 female) ranging in age from 20 days to 11 months (mean age, 8.3 months) and ranging in weight from 3.2 to 7.4 kg (mean 6.2 kg) underwent reconstruction of the right ventricular outflow tract using this surgical technique (tetralogy of Fallot/pulmonary atresia, 3 cases; truncus arteriosus, 1 case; double-outlet right ventricle, 1 case).

There were no operative deaths and no instances of valve-related complications at a mean follow-up of 19 months. Serial echocardiography shows mild homograft stenosis in 1 patient (15 mm Hg) and mild homograft insufficiency in 1 patient.

Although a longer follow-up is certainly required to determine whether the surgically modified bicuspid homografts will be as durable as the intact ones when positioned in the right ventricular outflow tract, we believe that this technique may represent a valuable therapeutic alternative, at least in the short term, to the use of synthetic grafts when an appropriately sized homograft is not available.