TY - JOUR
AU1 - Miyazaki,, Takako
AU2 - Yamagishi,, Masaaki
AU3 - Yamamoto,, Yusuke
AU4 - Itatani,, Keiichi
AU5 - Asada,, Satoshi
AU6 - Fujita,, Shuhei
AU7 - Hongu,, Hisayuki
AU8 - Maeda,, Yoshinobu
AU9 - Yaku,, Hitoshi
AB - Abstract View largeDownload slide View largeDownload slide OBJECTIVES The objective of this study was to evaluate our late outcomes using expanded polytetrafluoroethylene (ePTFE) valved patches with bulging sinuses and a fan-shaped valve for right ventricular outflow tract (RVOT) reconstruction. METHODS Six hundred and ninety patients underwent RVOT reconstruction using fan-shaped ePTFE valves and ePTFE valved patches with a bulging sinus. The patients’ median age and weight were 1.3 years [range 4 days–64.2 years, interquartile range (IQR) 0.9–2.3 years] and 8.7 (range 2.8–83.1, IQR 7.4–10.5) kg, respectively. The patches were monocuspid in 634 patients, bicuspid in 49 patients and tricuspid in 7 patients. Preoperative and postoperative data were collected retrospectively from the patients’ medical records. The longest follow-up period was 17.5 (7.6 ± 3.9) years. RESULTS There were no deaths related to the ePTFE patch. Pulmonary insufficiency was less than mild in 77.3%, and the peak RVOT gradient was <36 mmHg in 92.3% at the latest follow-up. Redo of RVOT reconstruction was performed in 40 patients, in no cases because of patch infection. Overall freedom from reoperation at 5, 10 and 15 years was 96.5%, 93.1% and 87.9%, respectively; by patient age, the rates at 5, 10 and 15 years for those younger than 1 year were 93.2%, 91.0% and 88.9%, respectively, while for those 1 year or older, they were 97.9%, 94.0% and 88.3%, respectively. CONCLUSIONS Satisfactory long-term outcomes were achieved with ePTFE patches with a bulging sinus and a fan-shaped valve. This ePTFE valved patch could be the optimal choice for RVOT reconstruction. Expanded polytetrafluoroethylene valved patch, Right ventricular outflow tract reconstruction, Sinus INTRODUCTION Right ventricular outflow tract (RVOT) to pulmonary artery (PA) continuity reconstruction has become one of the most common surgical procedures for patients with a wide variety of congenital heart diseases. The surgical management of RVOT and the prosthetic material for RVOT reconstruction remain controversial. Valved conduits or patches are the most common techniques to reconstruct the RVOT. Reliable valves require good performance to maintain good right ventricular function over the long term, because of their impact on patients’ outcomes, especially for younger children. Bovine jugular veins (Contegra; Medtronic, Inc., Minneapolis, MN, USA) and homografts have been the most commonly used materials for RVOT reconstruction, but they were shown to be prone to early calcification and degeneration of valve function as inevitable complications [1]. It was unfortunate that their long-term durability and availability were found to be unsatisfactory [2–4]. Expanded polytetrafluoroethylene (ePTFE) has low tissue affinity, with minimal cellular and fibrous deposition, which is a common cause of valvular dysfunction [4, 5]. For patients with congenital heart disease, especially younger children, maintaining good valve function is essential. Thus, we considered not only the valve material, but also the design of the valve leaflet and the structure of the native semilunar valve with the sinus of Valsalva. Therefore, we invented a fan-shaped valve [4] and a bulging sinus [5] on the graft to mimic the sinus of Valsalva, and we previously reported the mid- to long-term results, which showed excellent valvular function [4–9]. This paper presents our experience with ePTFE valved patches with bulging sinuses and fan-shaped valves (Figs 1 and 2) in RVOT reconstruction. Figure 1: View largeDownload slide A valved patch. (A) View from outside, the form of the bulging sinus. (B) View from inside. Figure 1: View largeDownload slide A valved patch. (A) View from outside, the form of the bulging sinus. (B) View from inside. Figure 2: View largeDownload slide (A) The shape of the expanded polytetrafluoroethylene fan-shaped leaflet. (B) Dimensions (a–a′, b–b′, h1, h, h2) of the fan-shaped leaflet according to the diameter of the sinus. The values of these 5 dimensions are the same in monocuspid and tricuspid leaflets, but b–b′ is different from the bicuspid valve and is noted in brackets. Figure 2: View largeDownload slide (A) The shape of the expanded polytetrafluoroethylene fan-shaped leaflet. (B) Dimensions (a–a′, b–b′, h1, h, h2) of the fan-shaped leaflet according to the diameter of the sinus. The values of these 5 dimensions are the same in monocuspid and tricuspid leaflets, but b–b′ is different from the bicuspid valve and is noted in brackets. MATERIALS AND METHODS This study was approved by the Institutional Review Board of Kyoto Prefectural University of Medicine (RBMR-C-657-1, January 15, 2010). In Japan, these valved patches have now been used at 65 institutes. We made all of the patches that were implanted in this study. Each institute asked us to make the patches prior to the operation, and the bulging sinus was formed using stainless steel moulds with a pedestal and cover, as described previously (Fig. 3) [5]. The pedestal has 3 cavities with the same diameter in its centre, with the cavities having one of 4 diameters (13.5, 15, 17.5 and 20 mm), or the diameter of the cavities is equal to the diameter of the bulging sinus. Mould covers containing 1, 2 or 3 folds are used for making monocuspid, bicuspid or tricuspid valves, depending on the expected diameter of the RVOT. After formation of the bulging sinus, the fan-shaped valve was sutured around the edge of the bulging sinus in the operating room [5]. All patches were created and sterilized in advance and delivered to the Japanese institutes as needed. Figure 3: View largeDownload slide (A) The stainless steel mould used to create the patch has a pedestal (top) and 3 covers (bottom) containing 1–3 holes. (B) Procedure for creating sinuses in an ePTFE patch. (a) The ePTFE patch is sandwiched between the cover and the pedestal of the stainless steel mould (lateral view). (b) Sinuses are created in the ePTFE patch by vacuum suction, which pulls the patch into the cavities in the pedestal of the mould. The shape of the sinuses on ePTFE is set by heating. ePTFE: expanded polytetrafluoroethylene. Figure 3: View largeDownload slide (A) The stainless steel mould used to create the patch has a pedestal (top) and 3 covers (bottom) containing 1–3 holes. (B) Procedure for creating sinuses in an ePTFE patch. (a) The ePTFE patch is sandwiched between the cover and the pedestal of the stainless steel mould (lateral view). (b) Sinuses are created in the ePTFE patch by vacuum suction, which pulls the patch into the cavities in the pedestal of the mould. The shape of the sinuses on ePTFE is set by heating. ePTFE: expanded polytetrafluoroethylene. Data source This was a multicentre study, with each patient followed up at the respective institute. Preoperative and postoperative data were collected retrospectively from the patients’ medical records at each institute. Statistical analysis Statistical analysis was performed using JMP, Version 10.0.2 (SAS Institute Inc., Cary, NC, USA). All continuous data are expressed as means ± standard deviation, medians, range and interquartile range (IQR). The Kaplan–Meier product limit method was used to analyse patient survival and freedom from reoperation, and 95% confidence limits are shown by the coloured areas around the Kaplan–Meier curves. Assessment of valve function To determine the mean blood pressure gradients between the right ventricle (RV) and the PA and assess the presence of pulmonary regurgitation, all patients underwent periodic transthoracic, 2-dimensional, colour flow, M-mode Doppler echocardiography during follow-up at each institute. All criteria used for grading were based on the commonly used guidelines for echocardiograms [10]. Quantitative assessment of pulmonary stenosis severity is based mainly on the transpulmonary pressure gradient using continuous Doppler. Grading of pulmonary stenosis was as follows: severe stenosis, peak jet velocity >4 m/s (peak gradient > 64 mmHg); moderate stenosis, peak jet velocity of 3–4 m/s (peak gradient 36–64 mmHg); and mild stenosis, peak jet velocity <3 m/s (peak gradient < 36 mmHg). The degree of pulmonary regurgitation was classified based on a 5-grade semi-quantitative scale (0, none; 1, trivial; 2, mild; 3, moderate; or 4, severe) according to the features of the jet flow as measured by pulsed Doppler echocardiography. RESULTS Patient profile A total of 690 patients underwent RVOT reconstruction using only ePTFE valved patches with bulging sinuses and fan-shaped ePTFE valves between February 2001 and January 2015 in 65 Japanese institutes. No conduit cases were included in this study. Only patients undergoing primary correction for congenital heart disease were included, and patients undergoing palliative procedures were excluded. The anatomical diagnoses are summarized in Table 1. Table 1: Anatomic diagnoses Diagnosis Procedure Number TOF/DORV/VSD + pul. atresia Construction of RV–PA continuity 122 TOF/DORV/VSD + PS 474 TOF + APV 36 PA + IVS 8 TGA + PS 2 cTGA + pul. atresia 6 cTGA + PS 4 Truncus arteriosus 6 Others 21 Subtotal 679 AS Ross/Ross–Konno procedure 4 ASR 3 AR 4 Other 0 Subtotal 11 Total 690 Diagnosis Procedure Number TOF/DORV/VSD + pul. atresia Construction of RV–PA continuity 122 TOF/DORV/VSD + PS 474 TOF + APV 36 PA + IVS 8 TGA + PS 2 cTGA + pul. atresia 6 cTGA + PS 4 Truncus arteriosus 6 Others 21 Subtotal 679 AS Ross/Ross–Konno procedure 4 ASR 3 AR 4 Other 0 Subtotal 11 Total 690 APV: absent pulmonary valve; AR: aortic regurgitation; AS: aortic stenosis; ASR: aortic stenosis with regurgitation; cTGA: corrected transposition of the great arteries; DORV: double-outlet right ventricle; IVS: intact ventricular septum; pul.: pulmonary; PS: pulmonary stenosis; RV: right ventricle; TGA: transposition of the great arteries; TOF: tetralogy of Fallot; VSD: ventricular septal defect. Table 1: Anatomic diagnoses Diagnosis Procedure Number TOF/DORV/VSD + pul. atresia Construction of RV–PA continuity 122 TOF/DORV/VSD + PS 474 TOF + APV 36 PA + IVS 8 TGA + PS 2 cTGA + pul. atresia 6 cTGA + PS 4 Truncus arteriosus 6 Others 21 Subtotal 679 AS Ross/Ross–Konno procedure 4 ASR 3 AR 4 Other 0 Subtotal 11 Total 690 Diagnosis Procedure Number TOF/DORV/VSD + pul. atresia Construction of RV–PA continuity 122 TOF/DORV/VSD + PS 474 TOF + APV 36 PA + IVS 8 TGA + PS 2 cTGA + pul. atresia 6 cTGA + PS 4 Truncus arteriosus 6 Others 21 Subtotal 679 AS Ross/Ross–Konno procedure 4 ASR 3 AR 4 Other 0 Subtotal 11 Total 690 APV: absent pulmonary valve; AR: aortic regurgitation; AS: aortic stenosis; ASR: aortic stenosis with regurgitation; cTGA: corrected transposition of the great arteries; DORV: double-outlet right ventricle; IVS: intact ventricular septum; pul.: pulmonary; PS: pulmonary stenosis; RV: right ventricle; TGA: transposition of the great arteries; TOF: tetralogy of Fallot; VSD: ventricular septal defect. The age at the time of surgery was 3.1 ± 6.4 years (median 1.3 years, range 4 days–64.2 years, IQR 0.9–2.3 years); 212 patients (30.7%) were younger than 1 year of age. The weight of the patients at the time of operation was 11.8 ± 11.2 (median 8.7, range 2.8–83.1, IQR 7.4–10.5) kg. A total of 75 patients (10.9%) had previous RVOT reconstruction with prosthetic valves. The patches were monocuspid in 634 patients, bicuspid in 49 patients and tricuspid in 7 patients. For the patients with a monocuspid patch, the diameters of the bulging sinus were 13.5 mm in 201 patients, 15 mm in 248, 17.5 mm in 80, 20 mm in 56 and unknown in 49. The follow-up time was 7.6 ± 3.9 (median 7.6, range 0–17.5, IQR 4.2–10.3) years. Overall, 414 patients (60.0%) underwent postoperative cardiac catheterization and 38 patients (5.5%) underwent postoperative magnetic resonance imaging (MRI). Of the total of 671 patients, the data of the most recent echocardiograms, cardiac catheterization or MRI related to valve function were obtained from 690 patients. Patient survival There were 8 (1.2%) early deaths within 30 days after patch implantation. The causes of early death were heart failure in 3 patients, sudden death in 2 patients, a pulmonary hypertensive crisis in 1 patient, respiratory failure in 1 patient and other causes in 1 patient. There were 19 (2.8%) late deaths beyond 30 days after patch implantation. The causes of early death were infection in 6 patients, respiratory failure in 4 patients, heart failure in 2 patients, arrhythmia in 2 patients, sudden death in 2 patients, other causes in 2 patients and unknown causes in 1patient. However, none of these deaths was related to the valves. The patient survival was 96.3% [95% confidence interval (CI) 94.5–97.5%] at 5 years, 96.1% (95% CI 94.3–97.3%) at 10 years and 95.4% (95% CI 93.1–97.0%) at 15 years (Fig. 4). Figure 4: View largeDownload slide Kaplan–Meier survival curve. Figure 4: View largeDownload slide Kaplan–Meier survival curve. Valve function Valve function was evaluated at the latest follow-up at a median time of 4.6 years. The degree of pulmonary regurgitation during the follow-up period was none in 29 patients (4.5%), trivial in 104 patients (16.3%), mild in 361 patients (56.3%), moderate in 139 patients (21.7%) and severe in 8 patients (1.2%) (Fig. 5A) (Table 1). Figure 5: View largeDownload slide (A) Pulmonary regurgitation. (B) Conduit stenosis. Figure 5: View largeDownload slide (A) Pulmonary regurgitation. (B) Conduit stenosis. The peak pressure gradient across the RVOT was 14.5 ± 12.8 (median 11.0, range 0–98.0, IQR 5–20) mmHg (Video 1). RVOT stenosis during the follow-up period was graded as mild or less in 590 patients (92.3%), moderate in 39 patients (6.1%) and severe in 10 patients (1.6%) (Fig. 5B). Video 1: Magnetic resonance angiography after RVOT reconstruction using a monocuspid patch. The sinus is formed, and ePTFE valve motion is smooth. ePTFE: expanded polytetrafluoroethylene; RVOT: right ventricular outflow tract. Video 1: Magnetic resonance angiography after RVOT reconstruction using a monocuspid patch. The sinus is formed, and ePTFE valve motion is smooth. ePTFE: expanded polytetrafluoroethylene; RVOT: right ventricular outflow tract. Close Right ventricular end-diastolic volume The right ventricular end-diastolic volume index (RVEDVI) was measured in 243 patients, and it was >150 ml/m2 in 33 patients (13.6%) and >170 ml/m2 in 11 patients (4.5%). Percutaneous transluminal angioplasty for pulmonary stenosis A total of 69 patients (10.0%) required a catheter intervention, including 57 balloon dilatations for peripheral PA stenosis, 8 for valvular stenosis and 4 for suprapulmonary valvular stenosis. Redo of right ventricular outflow tract reconstruction A total of 40 patients (5.8%) required redo of RVOT reconstruction after patch implantation, with an interval of 5.2 ± 3.0 (median 4.8, range 0.1–10.8, IQR 2.8–7.5) years. The cause of redo was RVOT stenosis in 24 patients, pulmonary regurgitation in 4 patients, pulmonary stenosis and regurgitation in 5 patients, infected endocarditis in 1 patient (but no valve infection), with a concomitant procedure in 3 patients and unknown cause in 3 patients. Freedom from redo of RVOT reconstruction was 96.5% (95% CI 94.7–97.7%) at 5 years, 93.1% (95% CI 90.2–95.1%) at 10 years and 87.9% (95% CI 82.3–91.9%) at 15 years (Fig. 6A). Examining freedom from redo of RVOT reconstruction by patient age at the time of patch implantation, the rates for those younger than 1 year were 93.2% (95% CI 88.3–96.1%) at 5 years, 91.0% (95% CI 84.9–94.7%) at 10 years and 88.9% (95% CI 81.1–93.7%) at 15 years, while for those 1 year old or older, they were 97.9% (95% CI 96.0–98.9%) at 5 years, 94.0% (95% CI 90.6–96.2%) at 10 years and 88.3% (95% CI 81.7–92.7%) at 15 years (Fig. 6B). No valves were placed in these patches using a catheter-based approach. Figure 6: View largeDownload slide Kaplan–Meier freedom from redo of right ventricular outflow tract reconstruction. (A) Overall freedom from patch exchange. (B) Freedom from patch exchange by patient age at the time of patch implantation. Figure 6: View largeDownload slide Kaplan–Meier freedom from redo of right ventricular outflow tract reconstruction. (A) Overall freedom from patch exchange. (B) Freedom from patch exchange by patient age at the time of patch implantation. DISCUSSION In cardiac surgery for congenital heart disease, RVOT reconstruction is one of the most common procedures. A transannular patch and valved conduit are 2 additional methods to reconstruct the RVOT. Patches were typically used for patients with congenital heart diseases with a narrow pulmonary annulus, such as tetralogy of Fallot. We typically use conduits for patients with discontinuity between the RV and the PA, such as pulmonary atresia, truncus arteriosus or Ross candidates. In this study, all patients underwent RVOT reconstruction using only patches that were monocuspid, bicuspid or tricuspid. The posterior wall of the RVOT was native tissue, even for patients with lack of continuity between the RV and PA, and for those patients, the posterior wall of the RVOT was reconstructed using materials such as autologous pericardium. However, bicuspid and tricuspid valves were not used as much as before for 2 main reasons. One is that the long-term outcomes of conduits, even small conduits, were satisfactory [8], and we therefore prefer conduits rather than bicuspid or tricuspid patches for those patients. The other main reason is that, from the perspective of fluid dynamics, the flow rate is high on the side of greater curvature; thus, positioning a valve on that side is important to prevent pulmonary regurgitation. Therefore, monocuspid patches are ideal. In 1993, Yamagishi and Kurosawa [11] independently introduced a 0.1-mm ePTFE pericardial membrane as a readily available material with good characteristics for monocusp valve construction and an ideal shape of the fan-shaped valve. Furthermore, on engineering assessment using a paediatric right heart stimulator with a pneumatic artificial heart, the presence of bulging sinuses demonstrated a larger effective opening area, a lower energy loss at the valve and a faster response in valve movement [12]. In addition, the presence of bulging sinuses and fan-shaped valves demonstrated a lower pressure gradient through the valves and less regurgitant flow at the valve [12]. The combination of a bulging sinus and a fan-shaped valve experimentally demonstrated the best valve function to prevent pulmonary regurgitation as well as stenosis [6, 12]. Scavo and Brown [13] reported that their animal studies suggested that 0.1 mm PTFE functioned better than glutaraldehyde-treated pericardium. In addition, we had some cases in which we removed some conduits for conduit exchange and examined them histologically [9]. There was very little calcification in the ePTFE material compared to other bioprosthetic valves. Furthermore, ePTFE was widely used for RVOT reconstruction, and excellent results were reported [4–9, 13–16]; thus, ePTFE might be the best material for RVOT reconstruction. However, in our histological examinations of ePTFE, [14] some cases showed a small amount of lymphohistiocytic inflammation and mineralization, which may lead to compromised mobility of the leaflet. To maintain good valve function over the long term, development and improvement of the ePTFE material itself to avoid mineralization will be needed, and we give low-dose aspirin, 2 mg/kg/day, for 6 months or longer to avoid lymphohistiocytic inflammation that might provoke mineralization. Early valvular failure due to local thrombotic processes leading to early valvular failure is another significant complication after Contegra conduit implantation [17–19]. On the other hand, there was no evidence of thrombosis despite not administering warfarin after patch implantation, which meant that ePTFE had good antithrombogenicity. Brown et al. [14–16] reported excellent results of a PTFE monocuspid patch. However, their surgical technique differed from that of ours. They determined the size of the patch, trimmed it at the time of operation and anastomosed the PTFE monocusp directly to the right ventricular myocardium, with anastomosis of another patch to cover the RVOT [14]. However, we prepared the valved patches prior to the operation, and therefore it was easy to decide on the positioning of the leaflet and anastomosis only in the RVOT. Because of the long circular margin of the fan-shaped valve, on the top of the cusp did not prolapse towards the right ventricle, and the cusp had a large coaptation zone. Moreover, they reported [14] that endocarditis, RVOT pseudoaneurysm, and supravalvular or subvalvular stenosis, rarely at the valve level, were the most common indications for reoperation of PTFE monocusp outflow tract patches within the first 5 years after initial insertion. In our series, there were no cases of RVOT pseudoaneurysm, but there were cases of supravalvular or subvalvular stenosis, rarely at the valve level, and we have been more aggressive during the initial repair to prevent these problems. In addition, Meyns et al. [20] reported that the incidence of severe anastomosis site stenosis of bovine jugular vein conduits was high. Overall, 29% of the Contegra conduits (17 patients) required an endovascular intervention (balloon dilatation or stent). In the present series, 10.0% of patients (69 patients) required endovascular intervention for anastomosis site stenosis, which is relatively low. It is important to take care of the anastomosis site of the PA to prevent supravalvular stenosis. Indeed, the ePTFE patch is harder than Contegra, a homograft or pericardium. A special technique must be used to anastomose it to the native PA to prevent stenosis. Yamagishi [21] described reconstruction using valved conduits and the way to perform it using patches. If stenosis is present in the right and left pulmonary arteries, augmentation of the pulmonary arteries is performed using autologous pericardium or an ePTFE patch. Consequently, if stenosis is present near the PA bifurcation, it should be augmented to the greatest extent possible [9]. The incidence of Contegra infection was reported to be relatively high and resulted in reoperation [22, 23]. In contrast, there were no cases of ePTFE patch infection in patients who required reoperation. We regularly administer only cefazolin sodium prophylactically, at the time of skin incision, and every 6 h for 24 h. ePTFE is one of the best materials for RVOT reconstruction with regard to resistance to infection. The indication for pulmonary valve replacement due to pulmonary regurgitation was RVEDVI over 150 ml/m2, with no patients ‘spontaneously’ remodelling to normal right ventricular volume if operated on when RVEDVI was over 170 ml/m2 [24]. The results of valve function with ePTFE valved conduits with bulging sinuses and fan-shaped valves were reported in our previous paper [9]. Compared with our experience with conduits, the RVEDVI of patients with patches was >150 ml/m2 in 13.6% and >170 ml/m2 in 4.5%, and, at the same time, the RVEDVI of patients with conduits was >150 ml/m2 in 2.6% and >170 ml/m2 in 1.0% [9]; that is, the RVEDVI was rather high in patients with patches compared to that in conduit patients. Furthermore, pulmonary regurgitation graded less than mild was seen in 77.3% of patients with patches and in 95.9% of patients with conduits [9]. However, pulmonary regurgitation was rarely the cause of redo RVOT reconstruction, which meant that the patches appeared to effectively control pulmonary insufficiency. While pulmonary regurgitation may not be the main cause of a relatively high RVEDVI value in patients with patches, other causes must be considered, for example, the length of the right ventricular incision. Thus, patches can be an appropriate choice because right ventricular function was preserved from pulmonary regurgitation and right ventricular dilatation. Furthermore, Kumar and Brown [14] reported that right ventricular dilatation producing fatigue was the most common indication for reoperation at between 5 and 20 years. Kaplan–Meier freedom from reoperation was 93% at 5 years, 84% at 10 years and 59% at 15 years, and it approached 30% at 20 years, dropping to a lower value after 15 years. Thus, further follow-up of right ventricular function is necessary, and we must determine the advantage of the bulging sinus and the fan-shaped valve. It is noteworthy that the ePTFE valved patch with a bulging sinus and a fan-shaped valve demonstrated high freedom from reoperation, even for younger children after 10 years. Thus, RVOT reconstruction using ePTFE patches is an effective, easy and durable technique for the midterm in the majority of patients and may delay or obviate the redo of RVOT reconstruction in late follow-up. However, a conduit is a good choice in patients with right heart dysfunction who need to have pulmonary regurgitation controlled and in adolescents and adults, even in younger children, with the excellent longevity of small-sized conduits [8], who need pulmonary valve replacements. Although further development and improvements, such as prevention of calcification and determination of the best depth of the bulging sinus and the design of the fan-shaped valve are needed, these ePTFE patches with bulging sinuses and fan-shaped ePTFE valves could be the optimal choice for RVOT reconstruction even for younger children, with the advantages of prevention of pulmonary regurgitation and RVOT stenosis, resistance to infections and high freedom from reintervention. Limitations This study has some limitations. This study did not compare the use of ePTFE valved patches with other materials for RVOT reconstruction. Moreover, the diameters of the native pulmonary annulus and of the reconstructed pulmonary annulus, as well as the properties of the native pulmonary valves that constitute the posterior wall of the RVOT, which might have affected right ventricular function, were not collected. CONCLUSION The results of the present study show that a fan-shaped valve with bulging sinuses on ePTFE patches has beneficial effects on long-term valve function in RVOT reconstruction and prevents repeated heart surgery and postoperative degeneration. ACKNOWLEDGEMENTS The authors are grateful to all the institutions that were included in this study for providing data for this manuscript. Conflict of interest: Masaaki Yamagishi receives personal fees from W.L. Gore & Associates, Inc. as a consultant. All other authors declared no conflict of interest associated with this manuscript. REFERENCES 1 Boethig D , Thies WR , Hecker H , Breymann T. Mid term course after pediatric right ventricular outflow tract reconstruction: a comparison of homografts, porcine xenografts and Contegras . Eur J Cardiothorac Surg 2005 ; 27 : 58 – 66 . Google Scholar Crossref Search ADS PubMed 2 Homann M , Haehnel JC , Mendler N , Paek SU , Holper K , Meisner H. 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TI - Use of an expanded polytetrafluoroethylene valved patch with a sinus in right ventricular outflow tract reconstruction
JF - European Journal of Cardio-Thoracic Surgery
DO - 10.1093/ejcts/ezz089
DA - 2019-10-01
UR - https://www.deepdyve.com/lp/oxford-university-press/use-of-an-expanded-polytetrafluoroethylene-valved-patch-with-a-sinus-H6TMflkdyt
SP - 1
VL - Advance Article
IS - 
DP - DeepDyve
ER -