Contegra versus pulmonary homograft for right ventricular outflow tract reconstruction in newborns.

OBJECTIVES: Pulmonary homografts are standard alternatives to right ventricular outflow tract reconstruction in congenital heart surgery. Unfortunately, shortage and conduit failure by early calcifications and shrinking are observed for small-sized homografts in younger patients. In neonates, Contegra® 12 mm (Medtronic Inc., Minneapolis, Minnesota, United States of America) could be a valuable alternative, but conflicting evidence exists. There is no published study considering only newborns with heterogeneous pathologies. We retrospectively compared the outcomes of these two conduits in this challenging population. METHODS: Patients who underwent a right ventricular outflow tract reconstruction between January 1992 and December 2014 at the Hôpital Universitaire des Enfants Reine Fabiola were included. We retrospectively collected and analysed demographic, echocardiographic, surgical, and follow-up data. RESULTS: Of the 53 newborns who benefited from a right ventricular outflow tract reconstruction during the considered period, 30 received a Contegra 12 mm (mean age 15 ± 8 days), and 23 a small (9-14 mm) pulmonary homograft (mean age 10 ± 7 days). Overall mortality was 16.6% with Contegra versus 17.4% in the pulmonary homograft group (p = 0.98 log-rank). Operative morbidity and early re-operation for conduit failure were not significantly different between the two groups. Mean follow-up in this study is 121 ± 74 months. Survival free from re-operation was not different between the two groups (p = 0.15). Multivariable analysis showed that weight and significant early gradient were factors associated with anticipated conduit failure. CONCLUSIONS: Contegra 12 mm is a valid alternative to small pulmonary homografts in a newborn patient population. TRIAL REGISTRATION: NCT03348397.

Pulmonary valve replacement after right ventricular outflow tract reconstruction with homograft vs Contegra®: a case control comparison of mortality and morbidity.

BACKGROUND: Repair of congenital heart defects involving the right ventricular outflow tract may require the implantation of a right ventricle to pulmonary artery conduit. This conduit is likely to be replaced during childhood. This study compares the operative outcomes of the replacement procedure of Contegra® and homografts in pulmonary position. METHODS: From 1999 to 2016, 82 children underwent 87 right ventricle to pulmonary artery conduit replacements (60 Contegra® and 27 homografts). Demographics, operative and clinical data were obtained through a retrospective review of the medical records. The two groups were matched for comparison using propensity score matching. All the procedures were performed by the same team of surgeons. RESULTS: No statistically significant difference was observed between the two groups when considering the operative data for anesthesia, surgery, cardiopulmonary bypass and aortic clamping durations. A peroperative complication rate of 13.47% and 15.36% in Contegra® and homograft replacement groups respectively (p value = 0.758) was observed. There was no difference regarding the blood loss and fluid input. No statistically significant difference was observed between the two groups for the post-operative morbidity. We considered the Pediatric Risk of Mortality (PRISM) score, the day of extubation, the day of withdrawal of inotropic drugs, the length of the intensive care unit stay and the length of hospital stay. The overall mortality is 2.3% but there is no statistically significant difference between the two groups. CONCLUSION: Right ventricle to pulmonary artery conduit replacement procedure can be achieved with a low surgical morbidity or mortality, not influenced by the type of conduit that is replaced. Therefore, the choice between homograft or Contegra® for right ventricle to pulmonary artery reconstruction should not be influenced by the future surgical risk during the replacement procedure. TRIAL REGISTRATION: NCT03048071 . Registered 9 February 2017 (retrospectively registered).

Contegra 12 mm: How Long Can It Last?

Since the year 2000, we have used Contegra conduits for right ventricular outflow tract reconstruction in infants and newborns. Published reports of early and late results from multiple centers have included variable and inconsistent findings. Concerns about the durability of small conduits placed in younger infants have been expressed. We report an interesting experience with a 12-mm Contegra conduit that we explanted 16 years after implantation in the course of repair of truncus arteriosus (common arterial trunk) in an infant.

Implantation of an Absorb bioresorbable vascular scaffold in the stenotic aortopulmonary collateral artery of a young child with Alagille syndrome.

Stent implantation in children can be problematic due to the possibility of growth incapacity and difficulties during later surgery. For these reasons, bioresorbable stents may be a good alternative to conventional stents. We report our experience with implantation of an Absorb bioresorbable stent in the stenotic major aortopulmonary collateral artery (MAPCA) of a 1-year-old girl born with pulmonary atresia with ventricular septal defect.

Managing Ventricular Septal Defect with Associated Aortic Regurgitation: Two Decades of Experience.

BACKGROUND AND AIM OF THE STUDY: Ventricular septal defect (VSD) with aortic regurgitation (AR) is a well-known association. However, there is still no agreement about its management, particularly regarding the technical details of its operative treatment. The study aim was to describe all components of the syndrome and to evaluate the various techniques used with regards to its anatomical and functional features. METHODS: A total of 31 patients (mean age 7.4 years; range: 1.0-14.3 years) who underwent repair of VSD and AR between 1990 and 2013 was reviewed. The VSD was perimembranous in 22 patients, and subarterial in nine. Trusler's valvuloplasty technique was used in 15 patients, Yacoub's technique in seven, and Carpentier's technique (triangular resection) in four. Two patients underwent aortic valve replacement (AVR), and three patients with no significant aortic valve lesions underwent a simple patch repair of the VSD. RESULTS: The aortic valvuloplasty results were generally good, with an initial aortic valvuloplasty avoiding AVR. During the immediate postoperative period, valvuloplasty failure occurred in three patients, regardless of the technique used, and all three patients were reoperated on. The mean duration of follow up was 8.5 years (range: 3.2-20.6 years). The initial result was maintained in all patients, except for four who underwent late AVR. CONCLUSION: The study findings contributed to an analysis of VSD and AR, and helped to clarify the best surgical strategy. The results obtained suggest that adequacy of the initial repair is the most important determinant of subsequent evolution.

Plasma fibrinogen concentration is correlated with postoperative blood loss in children undergoing cardiac surgery. A retrospective review.

BACKGROUND: Fibrinogen supplementation is increasingly recommended with the use of rotational thromboelastometry (ROTEM). However, data regarding the paediatric population are sparse. OBJECTIVE: We aimed to assess the relationship between plasma fibrinogen concentration and postoperative blood loss in children undergoing cardiac surgery. DESIGN: Retrospective analysis. SETTING: Data prospectively recorded in our departmental database between September 2010 and January 2012. PATIENTS: Data from 156 children scheduled for congenital heart surgery with ROTEM performed at the end of cardiopulmonary bypass (CPB) were analysed. INTERVENTION: None. MAIN OUTCOME MEASURES: Abnormal bleeding was defined as blood loss that exceeded 10% of total blood volume within the first 6 postoperative hours. Logistic regression analyses were used to determine variables associated with bleeding. Correlation analyses and receiver operating characteristic (ROC) curves were designed to evaluate the relationship between blood loss and plasma fibrinogen concentration or ROTEM variables, if relevant. RESULTS: Thirty-six children were considered as 'bleeders' and 120 as 'nonbleeders'. Univariate and multivariate logistic regression analysis revealed time for wound closure, clot formation time, maximal clot firmness (MCF) and plasma fibrinogen concentration as variables independently associated with postoperative bleeding. MCF was best correlated with plasma fibrinogen concentration. ROC curves for blood loss versus fibrinogen concentration and MCF showed that a plasma fibrinogen concentration of 1.5 g l and a MCF value 3 mm or less could be used to predict blood loss. CONCLUSION: Post-CPB plasma fibrinogen concentration significantly influences blood loss in children undergoing cardiac surgery. A fibrinogen concentration of at least 1.5 g l or a MCF of at least 3 mm should accurately predict excessive blood loss in cardiac surgery children. Further prospective trials are needed to assess the effect of fibrinogen supplementation on postoperative blood loss in this population.

Endocarditis of bovine jugular vein conduit due to Q fever.

Contegra (Medtronic, Minneapolis, MN) conduits are routinely used in cases of right ventricular outflow tract reconstruction during congenital heart surgery. We report two cases of Q fever endocarditis involving Contegra conduits. Surgical treatment and distinct aspects of both unusual cases are described.

Ten-year experience with surgical treatment of adults with congenital cardiac disease.

The number of adults with congenital cardiac disease continues to increase, and adult patients are now more numerous than paediatric patients. We sought to identify risk factors for perioperative death and report our results with surgical management of adult patients with congenital cardiac disease. We retrospectively analysed in-hospital data for 244 consecutive adult patients who underwent surgical treatment of congenital cardiac disease in our centre between January, 1998 and December, 2007. The mean patient age was 27.2 plus or minus 11.9 years, 29% were in functional class III or IV, and 25% were cyanosed. Of the patients, half were operated on for the first time. A total of 61% of patients underwent curative operations, 36% a reoperation after curative treatment, and 3% a palliative operation. Overall mortality was 4.9%. Predictive factors for hospital death were functional class, cyanosis, non-sinus rhythm, a history of only palliative previous operation(s), and an indication for palliative treatment. Functional class, cyanosis, type of initial congenital cardiac disease (single ventricle and double-outlet right ventricle), and only palliative previous operation were risk factors for prolonged intensive care stay (more than 48 hours). The surgical management of adult patients with congenital cardiac disease has improved during recent decades. These generally young patients, with a complex pathology, today present a low post-operative morbidity and mortality. Patients having undergone palliative surgery and reaching adulthood without curative treatment present with an increased risk of morbidity and mortality. Univentricular hearts and double-outlet right ventricles were associated with the highest morbidity.

Ventricular septal defect closure in Taussig-Bing heart: the "pulmonic rule".

Accurate ventricular septal defect patch sizing and tailoring remain challenging in many surgical procedures. Surgical exposure frequently limits complete visualization of the ventricular septal defect. Moreover, examination of the heart cavity under cardioplegic arrest may lead to skewed appreciation of the ventricular septal defect caliber and shape. Here we describe a simple and safe surgical tip to predict the size and shape of the ventricular septal defect patch in Taussig-Bing malformation before starting extracorporeal circulation. The patch should be circular with a diameter equal to the under pressure, proximal, pulmonary artery diameter.

Ventricular septal defect closure in tetralogy of Fallot: the aortic rule.

Ventricular septal defect (VSD) closure is an important part of the surgical repair of tetralogy of Fallot and related anomalies. Visual appreciation of the VSD size (either transinfundibular or transatrial) can be misleading. My colleagues and I describe a simple and precise way to predict the size and shape of the VSD patch before extracorporeal circulation: the patch should be circular with a diameter identical to that of the mid ascending aorta.

Early results of valved bovine jugular vein conduit versus bicuspid homograft for right ventricular outflow tract reconstruction.

BACKGROUND: Homograft conduits are preferable for right ventricular outflow tract reconstruction in children, but their limited availability remains a major concern. Recently, a valve-containing segment of bovine jugular vein (Contegra, Medtronic Inc, Minneapolis, MN) has been introduced as a potential alternative conduit. METHODS: Early clinical and echocardiographic results of right ventricular outflow tract reconstruction were retrospectively compared between 41 children (mean age, 1.9 years), receiving a Contegra conduit and 36 patients (mean age, 2.7 years) with a size-reduced pulmonary homograft. RESULTS: Clinical outcome was comparable with two early deaths in the homograft group and one in the Contegra group. There were no conduit-related complications in either population. Early echocardiographic assessment showed only trivial to mild regurgitation in 9 homografts versus 17 Contegra conduits. The peak gradient across the right ventricular outflow tract conduit was comparable for both groups, although a larger number of patients, treated with a downsized homograft, had a small gradient at the distal junction with the pulmonary arteries (12 versus 6 patients). None of the patients had a gradient at the valvar level. CONCLUSIONS: The valved bovine jugular vein conduit offers a promising substitute for right ventricular outflow tract reconstruction in infants and children, with an early hemodynamic performance that compares favorably with downsized, bicuspid homografts. Clinical advantages are greater shelf availability and the natural continuity between valve and conduit, which allows proximal infundibular shaping without additional material. However, durability must be determined, even though most of these children will require right ventricular outflow tract reoperation after outgrowing the conduit.