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OBJECTIVES The aim of this study was to compare the performance of pulmonary homografts with stentless bioprosthetic valves [Medtronic Freestyle™ (Medtronic, Minneapolis, MN, USA)] in the pulmonary position in patients with congenital heart disease (CHD) younger than 20 years. METHODS Between January 2000 and December 2017, 215 patients were retrospectively identified from hospital databases in 3 congenital heart centres in Australia. Valve performance was evaluated using standard criteria. Propensity score matching was used to balance the 2 treatment groups. RESULTS Freedom from reintervention for patients who received a pulmonary homograft (n = 163) was 96%, 88% and 81% at 5, 10 and 15 years and for patients who received a Freestyle™ valve (n = 52) was 98%, 89% and 31% at 5, 10 and 15 years, respectively. Freedom from structural valve degeneration for patients with a homograft was 92%, 87% and 77% at 5, 10 and 15 years and for patients with a Freestyle valve was 96%, 80% and 14% at 5, 10 and 15 years, respectively. In the first 10 years, there was no difference in outcomes [reintervention hazard ratios (HR) = 0.69, 95% confidence intervals (CI) (0.20–2.42), P = 0.56; structural valve degeneration HR = 0.92 (0.34–2.51), P = 0.87]. After 10 years, the recipients of the Freestyle valves were at higher risk of both outcomes [reintervention HR = 7.89; 95% CI (2.79–22.34), P < 0.001; structural valve degeneration HR = 7.41 (2.77–19.84), P < 0.001]. The findings were similar when analysed by implantation in the orthotopic position and in the propensity-matched groups. CONCLUSIONS The Freestyle stentless bioprosthetic valve is a comparable alternative to cryopreserved pulmonary homografts up to 10 years after implantation when implanted in an orthotopic pulmonary position in patients younger than 20 years with CHD.

Pulmonary veno-occlusive disease is a rare form of primary pulmonary hypertension of unknown aetiology. Four On clinical examination he was a healthy boy without cyanosis who had neither tachycardia nor tachypnoea at rest. He was hypertensive with a blood pressure of 150/80 mm Hg. A right ventricular heave was present. Cardiac auscultation showed an accentuated pulmonary component of the second heart sound but no murmurs, and normal breath sounds were heard on auscultation of his chest. Chest radiography showed a normal cardiac outline but pulmonary changes were consistent with acute pulmonary oedema (fig 1).The patient underwent cardiac catheterisation. These original records were not available for review, but the haemodynamic findings were interpreted as being 'consistent with a left atrial lesion', whereas angiography showed normal cardiac anatomy. As a result of these apparent inconsistencies, surgical exploration of the right and left atria was performed. This showed the presence of four normal pulmonary veins and confirmed normal cardiac anatomy. During the operation the pulmonary artery peak systolic pressure was 50 mm Hg and the mean pulmonary

In our patient population, pulmonary homografts outperformed stented bioprosthetic valves within 5 years when implanted in the pulmonary position in patients aged 10-20 years. We recommend the use of a pulmonary homograft for pulmonary valve replacement in this age group in patients undergoing surgery for congenital heart disease.