Original article: cardiovascular
Cryopreserved homografts in the pulmonary position: determinants of durability

Presented at the Poster Session of the Thirty-sixth Annual Meeting of The Society of Thoracic Surgeons, Fort Lauderdale, FL, Jan 31–Feb 2, 2000.
https://doi.org/10.1016/S0003-4975(00)01788-4Get rights and content

Abstract

Background. The cryopreserved homograft has emerged as the pulmonary conduit of choice for the repair of many congenital heart defects. It is also used for pulmonary valve replacement in the Ross procedure. Because of a wide range of patient ages and diagnoses, the risk of homograft failure may vary.

Methods. We reviewed 185 consecutive pulmonary position implants performed between September 1985 and January 1999. We examined three age groups: patients less than 1 year of age (n = 53), patients 1 to 10 years of age (n = 46), and patients more than 10 years of age (n = 86).

Results. Five-year Kaplan-Meier homograft survival was 25%, 61%, and 81% for the groups, respectively (p < 0.02). Smaller homograft size, younger patient age, and truncus arteriosus were risk factors for homograft failure in univariate analysis (p < 0.05). Smaller homograft size was the only predictor for homograft failure in multivariate analysis (p < 0.001). Twenty of 99 implants in patients less than 10 years old underwent transcatheter intervention. The 3-year Kaplan-Meier implant survival of this group (79%) was not different from those who did not undergo intervention (77%, p = 0.84). Survival of aortic and pulmonary homografts in patients less than 10 years of age was not different (p = 0.35). Ross procedure implants appear to have optimal survival (94%) at 5 years. Non-Ross implants in patients more than 10 years of age have 76% 5-year Kaplan-Meier survival, which is not different from Ross patients (p = 0.33).

Conclusions. Small homografts have limited durability. Aortic homografts perform as well as pulmonary homografts in young patients. Once patients receive an “adult-size” homograft, at approximately 10 years of age, risk for implant failure approximates that of patients undergoing the Ross procedure. Transcatheter interventions, when indicated, may prolong homograft life.

Section snippets

Material and methods

One hundred eighty-five cryopreserved homografts were implanted in the pulmonary position at our institution between September 1985 and January 1999. These 185 implants form the basis for the subsequent analysis. This population includes homografts placed in an orthotopic position as well as onto the right ventricular free wall. A hood of autologous pericardium or prosthetic material was used to augment the anastomosis between the ventricular wall and the homograft.

On the basis of hypothesized

Results

Table 1 demonstrates that only primary implants for predominantly non-Ross procedure indications were performed in group 1 (n = 53). In contrast, group 2 (n = 46) contained an almost equivalent number of primary homograft implants (n = 26) and conduit changes (n = 20). More than half of group 3 (n = 86) were primary Ross procedure implants (n = 48), Of note, 11 of the 14 primary implants in the tetralogy of Fallot patients of group 3 were orthotopic pulmonary valve replacements for late

Comment

Previous analyses of pulmonary position cryopreserved homograft durability have reported variable results 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12. The current study seeks to address this variability on several levels. First, pulmonary position homografts are presently used in a wide range of procedures on patients of all ages and sizes. We sought to deal with this heterogeneity by dividing the entire study population into three patient age groups. The data in Table 1 and Figure 1 support the

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