Selection of a conduit for right ventricular outflow tract reconstruction (a literature review)

Relevance. For six decades, in reconstructing the right ventricular outflow tract, the choice of conduit has been – and remains – a challenge for cardiac surgeons. Among the vast number of available valve prostheses, the choice of material is still debated. Various allografts, xenografts, combinations of Dacron tube grafts with an incorporated occlusive element made of biological tissue, and mechanical materials exist. Synthetic prostheses with handcrafted valves made of expanded polytetrafluoroethylene (ePTFE) and bioresorbable tissue-engineered conduits are gaining popularity. The ongoing search for the optimal conduit is driven by unsatisfactory long-term outcomes of prosthetic function. The main issue is the in-evitable biodegradation of the material from which the prosthesis is made. Durability is the most important indicator of conduit quality.

Aim: To review conduits used for right ventricular outflow tract reconstruction based on an analysis of published literature.

Methods. A search for studies was conducted using the Medline (PubMed) and the Russian Science Citation Index (RSCI) databases with search queries, keywords, and logical operators.

Results. Based on a systematic literature review, aspects of conduit selection for implantation in the pulmonary position were examined, and the main complications as well as early and long-term postoperative outcomes are presented.

Conclusion. The choice of conduit for right ventricular outflow tract reconstruction remains a key factor determining the effectiveness of surgical treatment and long-term outcomes in patients of different age groups. Promising directions include the development and implementation of new biological and synthetic conduits capable of providing better long-term results and increasing the durability of the reconstruction.

1. Latus H., Gummel K., Rupp S. et al. Beneficial effects of residual right ventricular outflow tract obstruction on right ventricular volume and function in patients after repair of tetralogy of Fallot. Pediatr. Cardiol. 2013;34:424–430. https://doi.org/10.1007/s00246-012-0476-4

2. Omel'chenko A.Ju., Gorbatyh Ju.N., Sojnov I.A. et al. Hemodynamic and functional assessment of the right ventricle after radical correction of the tetrad of Fallot. Medicinskij al'manah. 2016;4(44):93–99. (In Russ.). https://doi.org/10.21145/2499-9954-2016-4-93-99

3. Broberg C.S., Aboulhosn J., Mongeon F.-P. et al. Prevalence of left ventricular systolic dysfunction in adults with repaired tetralogy of fallot. Am. J. Cardiol. 2011;107:1215–1220. https://doi.org/10.1016/j.amjcard.2010.12.026

4. Piazza L., Chessa M., Giamberti A. et al. Timing of pulmonary valve replacement after tetralogy of Fallot repair. Expert Rev. Cardiovasc. Ther. 2012;10(7):917–923. https://doi.org/10.1586/erc.12.67

5. Klinner W., Zenker R. Experience with correction of Fallot's tetralogy in 178 cases. Surgery. 1965;57:353–357. PMID: 14261573.

6. Rastelli G.C., Ongley P.A., David G.D. et al. Surgical repair for pulmonary valve atresia with coronary-pulmonary artery failure: Report of case. Mayo Clin. Proc. 1965;40:521–527. PMID: 14346186.

7. Ross D.N., Somerville J. Correction of pulmonary atresia with a homograft aortic valve. Lancet. 1966;2:1446–1447. https://doi.org/10.1016/s0140-6736(66)90600-3

8. Rastelli G.C., McGoon D.C., Wallace R.B. Anatomic correction of transposition of the great arteries with ventricular septal defect and subpulmonary stenosis. J. Thorac. Cardiovasc. Surg. 1969;58:545–551. PMID: 5387997.

9. Carpantier A. From valvular xenograft to valvular bioprothesis (1965– 1977). Med. Instrument. 1977;11:98–101.

10. Burakovskij V.I., Chekanov V.S. Krasikov L.I. Prosthetics of the trunk of the pulmonary artery with tetrad Fallot. Grudnaja hir.1976;5:3–7. (In Russ.).

11. Chekanov V.S., Krasikov L.I. The technique of manufacturing artificial valve-containing prostheses. Grudnaja hir. 1978;5:65–69. (In Russ.).

12. Podzolkov V.P., Zelenikin M.A., Gorbachevskij S.V., Zajcev V.V. The first experience of using alloaortic conduits in the correction of congenital heart defects. Grudnaja i serd.-sosud. Hir. 1993;5:25–27. (In Russ.).

13. Willetts R.G., Stickley J., Drury N.E. et al. Four right ventricle to pulmonary artery conduit types. J. Thorac. Cardiovasc. Surg. 2021;162:1324–1333. https://doi.org/10.1016/j.jtcvs.2020.12.144

14. Boethig D., Avsar M., Bauer U. et al. Pulmonary valve prostheses: patient’s lifetime procedure load and durability. Evaluation of the German National Register for Congenital Heart Defects. Interact. Cardiovasc. Thorac. Surg. 2022;34:297–306. https://doi.org/10.1093/icvts/ivab233

15. McMullan D.M., Oppido G., Alphonso N. et al. Evaluation of downsized homograft conduits for right ventricle-to-pulmonary artery reconstruction. J. Thoracic. Cardiovasc. Surg. 2006;132:66–71. https://doi.org/10.1016/j.jtcvs.2006.02.041

16. Meyns B., Jashari R., Gewillig M. et al. Factors influencing the survival of cryopreserved homografts. The second homograft performs as well as the first. Eur. J. Cardiothorac. Surg. 2005;28:211–216. https://doi.org/10.1016/j.ejcts.2005.03.041

17. Tweddell J.S., Pelech A.N., Frommelt P.C. et al. Factors affecting longevity of homograft valves used in right ventricular outflow tract reconstruction for congenital heart disease. Circulation. 2000;102(suppl. 3):III130–135. https://doi.org/10.1161/01.cir.102.suppl_3.iii-130

18. Boethig D., Goerler H., Westhoff-Bleck M. et al. Evaluation of 188 consecutive homografts implanted in pulmonary position after 20 years. Eur. J. Cardiothorac. Surg. 2007;32:133–142. https://doi.org/10.1016/j.ejcts.2007.02.025

19. Bielefeld M.R., Bishop D.A., Campbell D.N. et al. Reoperative homograft right ventricular outflow tract reconstruction. Ann. Thorac. Surg. 2001;71:482–488. https://doi.org/10.1016/S0003-4975(00)02521

20. Rodefeld M.D., Ruzmetov M., Turrentine M.W., Brown J.W. Reoperative right ventricular outflow tract conduit reconstruction: risk analyses at follow up. J. Heart Valve Dis. 2008;17:119–126. PMID: 18365579.

21. Konuma T., Devaney E.J., Bove E.L. et al. Performance of CryoValve SG decellularized pulmonary allografts compared with standard cryopreserved allografts. Ann. Thorac. Surg. 2009;88:849–855. https://doi.org/10.1016/j.athoracsur.2009.06.003

22. DeLeon S.Y., Tuchek J.M., Bell T.J. et al. Early pulmonary homograft failure from dilatation due to distal pulmonary artery stenosis. Ann. Thorac. Surg. 1996;61:234–236; discussion 236–237. https://doi.org/10.1016/0003-4975(95)00940-X

23. Burch P.T., Kaza A.K., Lambert L.M. et al. Clinical performance of decellularized cryopreserved valved allografts compared with standard allografts in the right ventricular outflow tract. Ann. Thorac. Surg. 2010;90:1301–1305. https://doi.org/10.1016/j.athoracsur.2010.05.024

24. Ruzmetov M., Shah J.J., Geiss D.M., Fortuna R.S. Decellularized versus standard cryopreserved valve allografts for right ventricular outflow tract reconstruction: a single-institution comparison. J. Thorac. Cardiovasc. Surg. 2012;143:543–549. https://doi.org/10.1016/j.jtcvs.2011.12.032

25. Shinoka T., Breuer C.K., Tanel R.E. et al. Tissue engineering heart valves: valve leaflet replacement study in a lamb model. Ann. Thorac. Surg. 1995;60:513–516. https://doi.org/10.1016/0003-4975(95)00733-4

26. Sarikouch S., Horke A., Tudorache I. Decellularized fresh homografts for pulmonary valve replacement: a decade of clinical experience. Eur. J. Cardiothorac. Surg. 2016;50(2):281–290. https://doi.org/10.1093/ejcts/ezw050

27. Bibevski S., Ruzmetov M., Fortuna R.S. et al. Performance of synergraft decellularized pulmonary allografts compared with standard cryopreserved allografts: results from multiinstitutional data. Ann. Thorac. Surg. 2017;103(3):869–874. https://doi.org/10.1016/j.athoracsur.2016.07.068

28. Nerem R.M. Cellular engineering. Ann. Biomed. Eng. 1991;19:529–545. https://doi.org/10.1007/BF02367396

29. Shinoka T., Imai Y., Ikada Y. Transplantation of a tissue-engineered pulmonary artery. N. Engl. J. Med. 2001;344:532–533. https://doi.org/10.1056/NEJM200102153440717

30. Sojnov I.A., Zhuravleva I.Ju., Kuljabin Ju.Ju. et al. Valve-containing conduits in pediatric cardiac surgery. Hirurgija. Zhurnal im. N.I. Pirogova. 2018;1:75–81. (In Russ.). https://doi.org/10.17116/hirurgia2018175-81

31. Hartz R.S., Deleon S.Y., Lane J. et al. Medtronic freestyle valves in right ventricular outflow tract reconstruction. Ann. Thorac. Surg. 2003;76:1896–1900. https://doi.org/10.1016/s0003-4975(03)01301-8

32. Brown J.W., Ruzmetov M., Rodefeld M.D. et al. Valved bovine jugular vein conduits for right ventricular outflow tract reconstruction in children: an attractive alternative to pulmonary homograft. Ann. Thorac. Surg. 2006;82:909–916. https://doi.org/10.1016/j.athoracsur.2006.03.008

33. Sekarski N., van Meir H., Rijlaarsdam M.E. et al. Right ventricular outflow tract reconstruction with the bovine jugular vein graft: 5 years’ experience with 133 patients. Ann. Thorac. Surg. 2007;84:599–605. https://doi.org/10.1016/j.athoracsur.2007.04.026

34. Bautista-Hernandez V., Kaza A.K., Benavidez O.J., Pigula F. A. True aneurysmal dilatation of a Contegra conduit after right ventricular outflow tract reconstruction: A novel mechanism of conduit failure. Ann. Thorac. Surg. 2008;86:1976–1977. https://doi.org/10.1016/j.athoracsur.2008.04.104

35. Bowman F.O., Hancock W.D., Malm J.R. A valve containing Dacron prosthesis. Arch. Surg. 1974;107:724–728. https://doi.org/10.1001/archsurg.1973.01350230076015

36. Kloevekorn W.P., Meisner H., Paek S.U., Sebening F. Long-term results after right ventricular outflow tract reconstruction with porcine bioprosthetic conduits. J. Card. Surg. 1991;6(suppl_IV):624–626. https://doi.org/10.1111/jocs.1991.6.4s.624

37. Takahashi Y., Tsutsumi Y., Monta O. et al. Expanded polytetrafluoroethylene-valved conduit with bulging sinuses for right ventricular outflow tract reconstruction in adults. Gen. Thorac. Cardiovasc. Surg. 2010;58(1):14–18. https://doi.org/10.1007/s11748-009-0527-9

38. Yamagishi M., Kurosawa H. Outflow reconstruction of tetralogy of Fallot using a Gore-Tex valve. Ann. Thorac. Surg. 1993;56:1414–1416; discussion 1416–1417. https://doi.org/10.1016/0003-4975(93)90700-r

39. Brown J.W., Ruzmetov M., Vijay P. et al. Right ventricular outflow tract reconstruction with a polytetrafluoroethylene monocusp valve: a twelve-year experience. J. Thorac. Cardiovasc. Surg. 2007;133:1336–1343. https://doi.org/10.1016/j.jtcvs.2006.12.045

40. Quintessenza J.A., Jacobs J.P., Morell V.O. et al. Initial experience with a bicuspid polytetrafluoroethylene pulmonary valve in 41 children and adults: a new option for right ventricular outflow tract reconstruction. Ann. Thorac. Surg. 2005;79:924–931. https://doi.org/10.1016/j.athoracsur.2004.05.045

41. Scavo V.A. Jr., Turrentine M.W., Aufiero T.X. et al. Monocusp valve and transannular patch reconstruction of the right ventricular outflow tract: an experimental study. ASAIO J. 1998;44:M480–M485. https://doi.org/10.1097/00002480-199809000-00032

42. Ando M., Takahashi Y. Ten-year experience with handmade trileaflet polytetrafluoroethylene valved conduit used for pulmonary reconstruction. J Thorac. Cardiovasc. Surg. 2009;137:124–131. https://doi.org/10.1016/j.jtcvs.2008.08.060

43. Miyazaki T., Yamagishi M., Maeda Y. et al. Expanded polytetrafluoroethylene conduits and patches with bulging sinuses and fan-shaped valves in right ventricular outflow tract reconstruction: multicenter study in Japan. J. Thorac. Cardiovasc. Surg. 2011;142:1122– 1129. https://doi.org/10.1016/j.jtcvs.2011.08.018

44. Chang T.I., Chang C.I. An efficient way to make a trileaflet conduit for pulmonary valve replacement. Ann. Thorac. Surg. 2013;96:163–165. https://doi.org/10.1016/j.athoracsur.2013.09.081

45. Miyazaki T., Yamagishi M., Maeda Y. et al. Long-term outcomes of expanded polytetrafluoroethylene conduits with bulging sinuses and a fan-shaped valve in right ventricular outflow tract reconstruction. J. Thorac. Cardiovasc. Surg. 2018;155:2567–2576. https://doi.org/10.1016/j.jtcvs.2017.12.137

46. Poynter J.A., Eghtesady P., McCrindle B.W. et al. Association of pulmonary conduit type and size with durability in infants and young children. Ann. Thorac. Surg. 2013;96:1695–1701. https://doi.org/10.1016/j.athoracsur.2013.05.074

47. Kwak J.G., Bang J.H., Cho S. et al. Long-term durability of bioprosthetic valves in pulmonary position: pericardial versus porcine valves. J. Thorac. Cardiovasc. Surg. 2020;160:476–484. https://doi.org/10.1016/j.jtcvs.2019.11.134

48. Kan C.D., Wang J.N., Chen W.L. et al. Applicability of handmade expanded polytetrafluoroethylene trileaflet-valved conduits for pulmonary valve reconstruction: an ex vivo and in vivo study. J. Thorac. Cardiovasc. Surg. 2018;155:765–774. https://doi.org/10.1016/j.jtcvs.2017.09.049

49. Suzuki I., Shiraishi Y., Yabe S. et al. Engineering analysis of the effects of bulging sinuses in a newly designed pediatric pulmonary heart valve on hemodynamic function. J. Artif. Organs. 2012;15:49–56. https://doi.org/10.1007/s10047-011-0609-1

50. Chang T.I., Hsu K.H., Luo C.W. et al. In vitro study of trileaflet polytetrafluoroethylene conduit and its valve-in-valve transformation. Interact. Cardio. Vasc. Thorac. Surg. 2020;30:408–416. https://doi.org/10.1093/icvts/ivz274