Surgery for right ventricle to pulmonary artery conduit obstruction: risk factors for further reoperation.
OBJECTIVE
To identify the surgical approaches and risk factors which influence longevity of right ventricle to pulmonary artery (RV-PA) conduits following first reoperation for obstruction.


METHODS
Between January 1993 and August 2003, 114 patients underwent 141 reoperations for RV-PA conduit obstruction. Diagnoses included 'Truncus Arteriosus' (n=52), 'Pulmonary atresia/Tetralogy of fallot' (n=39), 'Double outlet right ventricle' (n=10), 'Transposition of great arteries, VSD, and pulmonary atresia' (n=9), and the 'Ross operation' (n=4). All patients had undergone a previous biventricular repair. The first reoperation for conduit obstruction was performed in 112 hospital survivors by: total conduit replacement (Group A, n=73) with valved (homograft=10 and xenograft=54) or non-valved (n=9) conduit, and patch enlargement of the obstructed RV outflow tract with preservation of the posterior and sides of the conduit wall after removing of the fibrocalcific peel and degenerated valve (Group B, n=39). Mean age at first reoperation was 8.8+/-6.7 and 7.5+/-5.3 years in patients of groups A and B, respectively. Seven patients in Group A and 18 in Group B required a second reoperation and two patients in Group B a third reoperation.


RESULTS
There were two hospital deaths and no late deaths. Mean follow-up was 5.8+/-3.2 years. Risk factors for second reoperation by univariate analysis were: homograft conduit use (P=0.004), Group B surgical approach (P=0.0001), higher RV-PA systolic pressure gradient at discharge (P=0.02), and age <5-years-old (P=0.01). Multivariate analysis showed that inclusion in Group B and younger age (<5-years-old) at repair were independent risk factors for second reoperation. Group B surgical approaches had higher RV-PA systolic pressure gradient at discharge (P=0.02) and required more PA bifurcation repair at the time of second reoperation (P=0.05). Freedom from second reoperation for conduit obstruction was significantly higher in Group A patients at 5 and 8 years (P<0.04) and those with xenografts rather than homograft (P=0.04).


CONCLUSIONS
Our results support the optimal surgical approach for RV-PA conduit obstruction is total replacement with a xenograft. RV outflow reconstruction by other techniques without complete dissection of PA bifurcation does not completely relieve the stenosis and could cause early restenosis. Higher systolic gradients at discharge and younger age at first reoperation are predictors of earlier reoperation.
Mohammadi
Siamak
S
Department of Pediatric Cardiac Surgery, Marie-Lannelongue Hospital, 133 Ave de la Résistance, 92350 Le Plessis-Robinson, France.
Belli
Emre
E
Martinovic
Ivo
I
Houyel
Lucile
L
Capderou
André
A
Petit
Jérome
J
Planché
Claude
C
Serraf
Alain
A
D000293:Adolescent; D000328:Adult; D006348:Cardiac Surgical Procedures / Q000379:methods; D002648:Child; D002675:Child, Preschool; D004310:Double Outlet Right Ventricle / Q000401:mortality / Q000601:surgery; D005260:Female; D006330:Heart Defects, Congenital / Q000401:mortality / Q000601:surgery*; D006345:Heart Septal Defects, Ventricular / Q000401:mortality / Q000601:surgery; D006352:Heart Ventricles / Q000601:surgery*; D006801:Humans; D007223:Infant; D008297:Male; D011183:Postoperative Complications / Q000601:surgery; D011651:Pulmonary Artery / Q000601:surgery*; D018633:Pulmonary Atresia / Q000401:mortality / Q000601:surgery; D012086:Reoperation; D012307:Risk Factors; D013771:Tetralogy of Fallot / Q000401:mortality / Q000601:surgery; D013997:Time Factors; D014188:Transposition of Great Vessels / Q000401:mortality / Q000601:surgery; D014338:Truncus Arteriosus / Q000601:surgery; D014694:Ventricular Outflow Obstruction / Q000401:mortality / Q000601:surgery*