title: Twenty-Year Outcome After Right Ventricular Outflow Tract Repair Using Heterotopic Pulmonary Conduits in Infants and Children.
abstract: Durability of pulmonary conduits (PCs) used for reconstruction of the right ventricular outflow tract (RVOT) may be affected by a variety of factors. Among these, the technique used for PC implantation, whether in orthotopic or heterotopic position, strictly dependent upon the underlying anatomy, has been suggested to influence long-term outcome after RVOT repair. To determine the outcome of heterotopic implantation in infants and children treated at our institution, late results of heterotopic PC in non-Ross patients were analyzed and compared with data of orthotopic PC in age-matched pediatric Ross patients operated during the same time period. Between November 1991 and January 2015, 58 infants and children, 32 male and 26 female, with a median age of 9.4 years (range 1 day-18 years) underwent implantation of heterotopic PC (31 homografts [HG] and 27 xenografts [XG]) for reconstruction of RVOT. Median age in the XG group was significantly lower than in the HG group (0.9 vs. 13.4 years, P = 0.01), while male/female ratio was similar. Fifty (86%) patients had undergone one or more prior cardiac operations, while 32 (55%) required associated procedures during PC implantation. Comparison with data in 305 children and with a median age of 9.4 years, receiving orthotopic PC between 1990 and 2012 (Italian Pediatric Ross Registry), was undertaken. Descriptive, univariate, and Kaplan-Meier analysis defined outcome. There were three (5.2%) early and five (9.0%) late deaths, during a median follow-up of 7.6 years (range 2 months-23 years). Patients having XG had trend toward higher hospital mortality (2/27 vs. 1/31, P = 0.2), but similar late mortality (2/24 vs. 3/30, P = 0.3). Overall survival was 88 and 62%, while freedom from PC replacement was 49 and 21%, at 10 and 20 years, respectively. The latter proved significantly worse than freedom from orthotopic PC replacement, which was 94 ± 2 and 70 ± 9% at 10 and 20 years (P = 0.02). When stratified for type of heterotopic PC, late survival proved comparable (81 and 81% for XG vs. 92 and 60% for HG, at 10 and 20 years, respectively, P = 0.7). However, freedom from PC replacement was significantly higher in patients with heterotopic HG (21 and 5% for XG vs. 63 and 48% for HG, at 10 and 20 years, respectively, P = 0.001). RVOT repair using either XG or HG in heterotopic position is a safe procedure associated with low hospital mortality and satisfactory late survival. Freedom from reoperation is significantly lower than that observed in age-matched children having orthotopic HG. Freedom from reoperation in heterotopic XG is poorer than in HG, although different baseline demography may have influenced this finding.
authors.affiliation: Division of Cardiac Surgery, Department of Surgery, University of Verona, Verona, Italy.
authors.forename: Stiljan
authors.initials: S
authors.lastname: Hoxha
authors.affiliation: Division of Cardiac Surgery, Department of Surgery, University of Verona, Verona, Italy.
authors.forename: Salvatore
authors.initials: S
authors.lastname: Torre
authors.affiliation: Division of Cardiac Surgery, Department of Surgery, University of Verona, Verona, Italy.
authors.forename: Alessio
authors.initials: A
authors.lastname: Rungatscher
authors.affiliation: Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy.
authors.forename: Camilla
authors.initials: C
authors.lastname: Sandrini
authors.affiliation: Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy.
authors.forename: Lucia
authors.initials: L
authors.lastname: Rossetti
authors.affiliation: Division of Cardiac Surgery, Department of Surgery, University of Verona, Verona, Italy.
authors.forename: Luca
authors.initials: L
authors.lastname: Barozzi
authors.affiliation: Division of Cardiac Surgery, Department of Surgery, University of Verona, Verona, Italy.
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Faggian
authors.affiliation: Division of Cardiac Surgery, Department of Surgery, University of Verona, Verona, Italy.
authors.forename: Giovanni Battista
authors.initials: GB
authors.lastname: Luciani
mesh_terms: D000293:Adolescent; D001705:Bioprosthesis; D001807:Blood Vessel Prosthesis; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000295:instrumentation* / Q000401:mortality; D002648:Child; D002675:Child, Preschool; D005260:Female; D006085:Graft Survival; D006330:Heart Defects, Congenital / Q000175:diagnosis / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D017052:Hospital Mortality; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D053208:Kaplan-Meier Estimate; D008297:Male; D011475:Prosthesis Failure; D011651:Pulmonary Artery / Q000503:physiopathology / Q000637:transplantation*; D012086:Reoperation; D012189:Retrospective Studies; D012307:Risk Factors; D013997:Time Factors; D014183:Transplantation, Heterologous; D016042:Transplantation, Heterotopic; D016896:Treatment Outcome
keywords: Congenital heart disease; Heterotopic pulmonary conduits; Right ventricular outflow tract repair