Homografts versus stentless bioprosthetic valves in the pulmonary position: a multicentre propensity-matched comparison in patients younger than 20 years†

Abstract

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.

Two Decades Using Stentless Porcine Aortic Root in Right Ventricular Outflow Tract Reconstruction

“…7,15 Other recent single institution reports have found that the porcine aortic root compares comparably favorably with pulmonary homografts in terms of conduit durability at up to 10 years of follow-up. 5,6 What remains to be seen is whether the trajectory of conduit dysfunction changes over time and whether patients will face an increasing likelihood of conduit reintervention. The early cardiac MRI data for more recent patients in this study indicate favorable conduit performance with positive RV remodeling, although more longitudinal follow-up for more patients is necessary.…”

“…Despite this added difficulty with surgical placement of the stentless porcine aortic root, numerous studies have demonstrated excellent short-to-medium term outcomes and rates of endocarditis ranging from 0-5%. [2][3][4][5][6][7] In this study, we aimed to evaluate medium-to-long term outcomes including valve durability and need for re-intervention following stentless porcine PVR for older adolescent and adult patients at our institution.…”

Seven decades of valved right ventricular outflow tract reconstruction: The most common heart procedure in children

“…[2][3][4] Heterotopic positioning may also adversely affect homograft durability. 5 Pulmonary allograft performance and longevity are significantly better following the Ross operation because many of the patients are older and an oversized pulmonary allograft is inserted in an orthotopic fashion, which alleviates the turbulent flow seen in extracardiac valved conduits.…”

“…15,16 Similar outcomes between stentless and stented bioprostheses have been observed up to 10 years post-implantation. 5,17,18 In 116 patients who underwent Freestyle PVR between 1998 and 2018, the 10-year freedom from reintervention was 94%, with only 2 suspected cases of endocarditis, neither of which required reintervention (Kasten MW, Herrmann JL, Brown JW, et al, unpublished data, 1998.…”

Commentary: Regression or progression: Hominum, bovinum, porcinum?

“…However, it should be clarified that head-to-head comparisons of the Freestyle with homografts with respect to these indices have been scant at best, and in the context of endocarditis management specifically, direct comparisons are nonexistent and thus such claims not substantiated. 10,11 Alternatively, in a recent study commensurate with the latter half of the Clemence and colleagues 1 study's era, 2011 to 2017, and in a specific cohort of patients with intravenous drug abuse (IVDA)associated endocarditis (all with annular/root abscess necessitating full root replacement and 70% were reoperations compared with only 20% IVDA, 58% root abscess and 41% reoperations in Clemence and colleagues) in whom homografts were used exclusively, the operative and 5-year survival rates were similar at 12% and 57% 12 compared with 7% and 58%, respectively. Interestingly, when studying the rate of and indication for readmissions through mid-term follow-up after valve surgery for a large endocarditis cohort (831 patients) and comparing those patients with and without IVDA-associated endocarditis, patients with a history of IVDA had a greater likelihood of recurrent endocarditis (33) but a slightly lower incidence of heart failure readmission than the non-IVDA cases.…”