Coronary Artery Complications after Right Ventricular Outflow Tract Reconstruction Surgery

Background:Mechanisms and clinical manifestations of coronary artery complications after right ventricular outflow tract reconstruction surgery are not well known.Methods:Patients who had coronary artery complications after pulmonary valve replacement or the Rastelli procedure at a single tertiary centre were retrospectively analysed.Results:Coronary artery complications were identified in 20 patients who underwent right ventricular outflow tract reconstruction surgery.The median age at diagnosis of coronary artery complication was 21 years(interquartile range:13–25 years).Mechanisms of coronary artery complications were compression by adjacent materials in 12 patients,dynamic compression of intramural course of coronary artery in two patients,and intraoperative injury in six patients.Congenital coronary artery anomalies were identified in 50%(10/20)of patients.Four patients presented with early postoperative haemodynamic instability.Fourteen patients showed late onset symptoms or signs of coronary insufficiency,including chest pain,ventricular dysfunction,or ventricular arrhythmias.Coronary artery stenosis was incidentally found on cardiac computed tomography angiography in two asymptomatic patients.Four patients underwent surgical interventions,and one patient underwent percutaneous coronary intervention for coronary stenosis.One patient with recurrent ventricular tachycardia required an implantable cardioverter-defibrillator.There were two deaths in patients with intraoperative coronary injury.Conclusion:Preoperative coronary evaluation and long-term follow-up for the development of coronary artery complications are required in patients undergoing right ventricular outflow tract reconstruction surgery to prevent ventricular dysfunction,arrhythmias,and death,especially among those with congenital coronary anomalies.

Handmade tri-leaflet ePTFE conduits versus homografts for right ventricular outflow tract reconstruction

Background This study aimed to investigate the performance of handmade tri-leaflet expanded polytetrafluoroethylene(ePTFE)conduits in the absence of a suitable homograft.Methods Patients who underwent right ventricular outflow tract reconstruction with tri-leaflet ePTFE conduits or homografts between December 2016 and August 2020 were included.The primary endpoint was the incidence of moderate or severe conduit stenosis(>36 mmHg)and/or moderate or severe insufficiency.The secondary endpoint was the incidence of severe conduit stenosis(>64 mmHg)and/or severe insufficiency.Results There were 102 patients in the ePTFE group and 52 patients in the homograft group.The median age was younger[34.5(interquartile range:20.8-62.8)vs.60.0(interquartile range:39.3-81.0)months,P=0.001]and the median weight was lower[13.5(10.0-19.0)vs.17.8(13.6-25.8)kg,P=0.003]in the ePTFE group.The conduit size was smaller(17.9±2.2 vs.20.5±3.0 mm,P<0.001)and the conduit Z score was lower(1.48±1.04 vs.1.83±1.05,P—0.048)in the ePTFE group.There was no significant difference in the primary endpoints(log rank,T3=0.33)and secondary endpoints(log rank,P=0.35).Multivariate analysis identified lower weight at surgery[P=0.01;hazard ratio:0.75;95%confidence interval(CI)0.59-0.94]and homograft conduit use(P=0.04;hazard ratio:8.43;95%CI 1.14—62.29)to be risk factors for moderate or severe conduit insufficiency.No risk factors were found for moderate or severe conduit stenosis or conduit dysfunction on multivariate analysis.Conclusion Handmade tri-leaflet ePTFE conduits showed acceptable early and midterm outcomes in the absence of a suitable homograft,but a longer follow-up is needed.