Outcomes after right ventricular outflow tract reconstruction with valve substitutes: A systematic review and meta-analysis

Abstract

IntroductionThis study aims to provide an overview of outcomes after right ventricular outflow tract (RVOT) reconstruction using different valve substitutes in different age groups for different indications.MethodsThe literature was systematically searched for articles published between January 2000 and June 2021 reporting on clinical and/or echocardiographic outcomes after RVOT reconstruction with valve substitutes. A random-effects meta-analysis was conducted for outcomes, and time-related outcomes were visualized by pooled Kaplan–Meier curves. Subgroup analyses were performed according to etiology, implanted valve substitute and patient age.ResultsTwo hundred and seventeen articles were included, comprising 37,078 patients (age: 22.86 ± 11.29 years; 31.6% female) and 240,581 patient-years of follow-up. Aortic valve disease (Ross procedure, 46.6%) and Tetralogy of Fallot (TOF, 27.0%) were the two main underlying etiologies. Homograft and xenograft accounted for 83.7 and 32.6% of the overall valve substitutes, respectively. The early mortality, late mortality, reintervention and endocarditis rates were 3.36% (2.91–3.88), 0.72%/y (95% CI: 0.62–0.82), 2.62%/y (95% CI: 2.28–3.00), and 0.38%/y (95%CI: 0.31–0.47) for all patients. The early mortality for TOF and truncus arteriosus (TA) were 1.95% (1.31–2.90) and 10.67% (7.79–14.61). Pooled late mortality and reintervention rate were 0.59%/y (0.39–0.89), 1.41%/y (0.87–2.27), and 1.20%/y (0.74–1.94), 10.15%/y (7.42–13.90) for TOF and TA, respectively. Endocarditis rate was 0.21%/y (95% CI: 0.16–0.27) for a homograft substitute and 0.80%/y (95%CI: 0.60–1.09) for a xenograft substitute. Reintervention rate for infants, children and adults was 8.80%/y (95% CI: 6.49–11.95), 4.75%/y (95% CI: 3.67–6.14), and 0.72%/y (95% CI: 0.36–1.42), respectively.ConclusionThis study shows RVOT reconstruction with valve substitutes can be performed with acceptable mortality and morbidity rates for most patients. Reinterventions after RVOT reconstruction with valve substitutes are inevitable for most patients in their life-time, emphasizing the necessity of life-long follow-up and multidisciplinary care. Follow-up protocols should be tailored to individual patients because patients with different etiologies, ages, and implanted valve substitutes have different rates of mortality and morbidity.Systematic review registration[www.crd.york.ac.uk/prospero], identifier [CRD42021271622].

Does heterotopically-placed right ventricle-to-pulmonary artery (RV-to-PA) conduit negatively affect its longevity, reintervention-free survival, and overall survival? Our experience.

“…Our results did not demonstrate TA to be a potential risk factor for conduit dysfunction, reintervention-free survival, and overall survival. We believed that the reason behind this was that patients with TA generally underwent surgical conduit placement much earlier in life, in which PVOD had not yet developed 15,16 . Also, we had very limited number of TA patients in our cohort, which might not be enough to be statistically signi cant.…”

A mid- and long-team follow-up study of the application of single-valved bovine pericardium patches in right ventricular outflow tract reconstruction

“…Furthermore, irreversible myocardial damage may occur ( 4 ). Although valved conduits have a good closure function, they have no growth potential and are associated with high reoperation rate; thus, they are not suitable for children ( 5 , 6 ). It has been widely recognized that autologous tissues should be spared as much as possible to avoid RVOT stenosis ( 7 ).…”

Pediatric pulmonary valve replacements: Clinical challenges and emerging technologies

“…No commercially available PPVRs are ideal and RVOT reconstruction will often require repeat operations later in life to replace dysfunctional prosthetics 18,19 . Importantly, freedom from RVOT reoperation varies depending on the clinical context, influenced by factors such as CHD etiology, age at implantation and PPVR type, as well as institutional and patient preferences.…”

“…A recent systematic review identified the primary indications for intervention due to right heart CHDs as Tetralogy of Fallot and truncus arteriosus, and left heart CHDs commonly required right heart intervention due to the use of the PV as an autograft in the Ross procedure 19 . PPVR implantation for truncus arteriosus tended to occur earlier in life (median age of 2.5 months), with a 10‐year freedom from reoperation of around 25% 19 .…”

“…Many CHDs affect the right ventricular outflow tract (RVOT) (Table 1), leading to a significant requirement for pulmonary valve (PV) replacement in the pediatric population 12–15 . The PV is one of four heart valves that mediate a strict unidirectional blood flow through the heart 16,17 ; however, the lack of ideal replacement prosthetics generates a requirement for repeat interventions throughout early life 18,19 . Prosthetics based on metals are prone to thrombosis and require lifelong anticoagulation, introducing additional burdens that persist past childhood, 20,21 while those based on biological materials exhibit underwhelming durability due to their immunogenicity and structural degradation 22,23 .…”