Pulmonary homograft monocusp reconstruction of the right ventricular outflow tract: outcomes to the intermediate term.

BACKGROUND: There is limited information on longer-term outcomes of pulmonary homograft monocusp (PHM) reconstruction of the right ventricular outflow tract (RVOT). METHODS: A retrospective review of 131 consecutive patients undergoing RVOT reconstruction with PHM was completed. RESULTS: Median age was 7.6 months (range, 1 day to 14 years) and weight was 7.3 kg (range, 2 to 65 kg). Most patients (108 of 131; 82%) underwent repair for Tetralogy. After PHM, median duration of mechanical ventilation was 1 day (range, 0 to 89) and hospital stay was 6.5 days (range, 2 to 137). Hospital mortality was 2% (3 of 131) with 1 patient undergoing early replacement of PHM. Echocardiogram at hospital discharge demonstrated peak RVOT gradient of 16 mm Hg (range, 4 to 64 mm Hg); and pulmonary insufficiency was absent/trivial in 40%, mild in 42%, moderate in 16%, and severe in 2%. Follow-up is completed in 91% of hospital survivors at a median of 5 years (range, 1 to 12). There were 5 late deaths, with an actuarial survival of 96% +/- 3.7%, 94% +/- 4.6%, and 89% +/- 9.2% at 1 year, 5 years, and 10 years, respectively. There were 24 reinterventions, including 10 pulmonary valve replacements. Median time to valve replacement was 1.9 years (range, 0.4 to 4.6). Actuarial freedom from pulmonary valve replacement was 97% +/- 3.0%, 90% +/- 6.1%, and 85% +/- 10.3% at 1 year, 5 years, and 10 years, respectively. Echocardiogram at last follow-up demonstrated no increase in RVOT gradient compared with hospital discharge (16 mm Hg), but there was significant increase in pulmonary insufficiency (mild 27%, moderate 39%, severe 34%). CONCLUSIONS: Pulmonary homograft monocusp reconstruction is an alternative strategy for RVOT reconstruction and provides early but gradually diminishing protection against pulmonary insufficiency without a risk of stenosis. As expected, PHM function decreases over time as the RVOT grows and the homograft tissue undergoes structural deterioration.

Can the Kawashima procedure be performed in younger patients?

BACKGROUND: The prudence of performing early palliative cavopulmonary connection that includes superior vena cava in association with azygous-hemiazygous continuation of the inferior vena cava, Kawashima procedure (KP), has been questioned. We document our experience with KP performed at a relatively younger age than usually reported. METHODS: A retrospective review of patients undergoing KP (October 2000 to April 2008) was done. RESULTS: Initial palliation was carried out in 13 of 15 patients. Age and weight at KP was 8.4 months (5.1 to 15.1) and 6.8 kg (4.6 to 11.0). The pre-KP catheterization showed the following: pulmonary artery pressure = 14.5 mm Hg (9 to 17); end-diastolic pressure of systemic ventricle = 8 (2 to 14); oxygenation saturation = 76% (63 to 82); and atrioventricular (AV) valve insufficiency moderate or greater in 5 patients. The post-KP characteristics included the following intubation = 1 day (0 to 19); nitric oxide = 4 patients; superior caval pressure = 14 mm Hg (6 to 18); inotrope score = 7.5 (2.5 to 14.3); intensive care unit stay = 3 days (1 to 9); hospital stay = 7 days (3 to 77); and oxygen saturation at discharge = 84% (76 to 90%). There was one hospital death that required takedown of KP. Fontan completion was performed in 8 patients at an interval of 2.7 years (1.8 to 5.8) after KP. There was one post-Fontan mortality from severe ventricular and AV valve dysfunction. Pulmonary arteriovenous malformations (PAVMs) were diagnosed in 4 patients with 3 resolving post-Fontan. With a median follow-up of 4.2 years (0.1 to 7.9), 13 of 15 remain alive yielding a series survival of 87%. CONCLUSIONS: The Kawashima procedure can be safely performed at an earlier age than previously reported. The incidence of PAVMs after the KP appears to be similar to other reports where KP was performed at a later age.