Simultaneous Aortic and Pulmonary Valve Replacement in Repaired Congenital Heart Disease

Abstract

Objectives Patients with congenital heart disease frequently require surgical or percutaneous interventional valve replacement after initial congenital heart defect (CHD) repair. In some of these patients, simultaneous replacement of both semilunar valves is necessary, resulting in increased procedural complexity, morbidity, and mortality. In this study, we analyze the outcomes of simultaneous aortic and pulmonary valve replacements following multiple surgical interventions for CHD.

Methods This was a retrospective study of 24 patients who after initial repair of CHD underwent single-stage aortic and pulmonary valve replacement at our institution between 2003 and 2021.

Results The mean age of the patients was 28 ± 13 years; the mean time since the last surgery was 15 ± 11 years. Decellularized valved homografts (DVHs) were used in nine patients, and mechanical valves were implanted in seven others. In eight patients, DVHs, biological, and mechanical valves were implanted in various combinations. The mean cardiopulmonary bypass time was 303 ± 104 minutes, and aortic cross-clamp time was 152 ± 73 minutes. Two patients died at 12 and 16 days postoperatively. At a maximum follow-up time of 17 years (mean 7 ± 5 years), 95% of the surviving patients were categorized as New York Heart Association heart failure class I.

Conclusion Single-stage aortic and pulmonary valve replacement after initial repair of CHD remains challenging with substantial perioperative mortality (8.3%). Nevertheless, long-term survival and clinical status at the latest follow-up were excellent. The valve type had no relevant impact on the postoperative course. The selection of the valves for implantation should take into account operation-specific factors—in particular reoperability—as well as the patients' wishes.

Keywords

congenital heart disease - aortic valve replacement - pulmonary valve replacement - mechanical valve - valve prosthesis - decellularized homografts

Authors' Contribution

D.B. was responsible for conceptualization; data curation; project administration; writing—original draft; and writing—review and editing.

K.H. was responsible for data curation; formal analysis; software; and writing—review and editing.

M.A. was responsible for data curation; formal analysis; and supervision.

T.C. was responsible for data curation; formal analysis; and resources.

E.P. was responsible for data curation; formal analysis; and supervision.

S.S. was responsible for data curation; formal analysis; supervision; writing—original draft; and writing—review and editing.

M.W.-B. was responsible for data curation; formal analysis; and supervision

G.H. was responsible for data curation; formal analysis; supervision; and writing—original draft.

A.H. was responsible for conceptualization; formal analysis; and supervision.

A.H. was responsible for conceptualization; data curation; formal analysis; project administration; supervision; writing—original draft; and writing—review and editing.

Publikationsverlauf

Eingereicht: 08. Dezember 2022

Angenommen: 30. Januar 2023

Accepted Manuscript online:
23. Februar 2023

Artikel online veröffentlicht:
29. März 2023

• References

• 1 Pabst von Ohain J, Tonino E, Kaemmerer H. et al. German Heart Centre Munich-45 years of surgery in adults with congenital heart defects: from primary corrections of septal defects and coarctation to complex reoperations. Cardiovasc Diagn Ther 2021; 11 (02) 492-502
• 2 Hörer J. Current spectrum, challenges and new developments in the surgical care of adults with congenital heart disease. Cardiovasc Diagn Ther 2018; 8 (06) 754-764
• 3 Vida VL, Triglia LT, Zanotto L. et al. Late management of the aortic root after repair of tetralogy of Fallot: A European multicentre study. J Card Surg 2020; 35 (01) 40-47
• 4 Ichikawa N, Shiina Y, Kijima Y. et al. Characteristics of the aortic root morphology in conotruncal anomaly of the congenital heart disease. J Cardiol 2022; 79 (02) 277-282
• 5 Henaine R, Azarnoush K, Belli E. et al. Fate of the truncal valve in truncus arteriosus. Ann Thorac Surg 2008; 85 (01) 172-178
• 6 Mokhles MM, Rizopoulos D, Andrinopoulou ER. et al. Autograft and pulmonary allograft performance in the second post-operative decade after the Ross procedure: insights from the Rotterdam Prospective Cohort Study. Eur Heart J 2012; 33 (17) 2213-2224
• 7 Holst KA, Dearani JA, Burkhart HM. et al. Reoperative multivalve surgery in adult congenital heart disease. Ann Thorac Surg 2013; 95 (04) 1383-1389
• 8 Niwa K, Perloff JK, Bhuta SM. et al. Structural abnormalities of great arterial walls in congenital heart disease: light and electron microscopic analyses. Circulation 2001; 103 (03) 393-400
• 9 McElhinney DB, Reddy VM, Rajasinghe HA, Mora BN, Silverman NH, Hanley FL. Trends in the management of truncal valve insufficiency. Ann Thorac Surg 1998; 65 (02) 517-524
• 10 Bhat AH, Smith CJ, Hawker RE. Late aortic root dilatation in tetralogy of Fallot may be prevented by early repair in infancy. Pediatr Cardiol 2004; 25 (06) 654-659
• 11 Ishizaka T, Ichikawa H, Sawa Y. et al. Prevalence and optimal management strategy for aortic regurgitation in tetralogy of Fallot. Eur J Cardiothorac Surg 2004; 26 (06) 1080-1086
• 12 Mongeon FP, Gurvitz MZ, Broberg CS. et al; Alliance for Adult Research in Congenital Cardiology (AARCC).. Aortic root dilatation in adults with surgically repaired tetralogy of Fallot: a multicenter cross-sectional study. Circulation 2013; 127 (02) 172-179
• 13 Ordovas KG, Keedy A, Naeger DM. et al. Dilatation of the ascending aorta is associated with presence of aortic regurgitation in patients after repair of tetralogy of Fallot. Int J Cardiovasc Imaging 2016; 32 (08) 1265-1272
• 14 Etnel JRG, Grashuis P, Huygens SA. et al. The Ross procedure: a systematic review, meta-analysis, and microsimulation. Circ Cardiovasc Qual Outcomes 2018; 11 (12) e004748
• 15 Ferraz Cavalcanti PE, Sá MPBO, Lins RFA. et al. Three-step preoperative sequential planning for pulmonary valve replacement in repaired tetralogy of Fallot using computed tomography. Eur J Cardiothorac Surg 2020; 59 (02) 333-340
• 16 Vida VL, Zanotto L, Torlai Triglia L. et al; On The Behalf Of The European Congenital Heart Surgeons Association Echsa. Surgery for adult patients with congenital heart disease: results from the European database. J Clin Med 2020; 9 (08) 2493
• 17 Bobylev D, Avsar M, Sarikouch S. et al. Valve-sparing aortic root replacement in adult patients with congenital heart disease. Interact Cardiovasc Thorac Surg 2021; 33 (06) 959-965
• 18 Horke A, Bobylev D, Avsar M. et al. Paediatric aortic valve replacement using decellularized allografts. Eur J Cardiothorac Surg 2020; 58 (04) 817-824
• 19 Sarikouch S, Horke A, Tudorache I. et al. Decellularized fresh homografts for pulmonary valve replacement: a decade of clinical experience. Eur J Cardiothorac Surg 2016; 50 (02) 281-290
• 20 Bobylev D, Breymann T, Boethig D, Haverich A, Ono M. Semilunar valve replacement with decellularized homograft after Damus-Kaye-Stansel anastomosis and fontan procedure. Ann Thorac Surg 2014; 97 (05) 1792-1795
• 21 Dearani JA, Burkhart HM, Stulak JM, Sundt TM, Schaff HV. Management of the aortic root in adult patients with conotruncal anomalies. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2009; (e-pub ahead of print)
• 22 Esaki J, Leshnower BG, Binongo JN. et al. Reoperative aortic root replacement: outcome in a contemporary series. J Thorac Cardiovasc Surg 2017; 154 (03) 800-808.e3
• 23 Dunne B, Xiao A, Litton E, Andrews D. Mechanical prostheses for right ventricular outflow tract reconstruction: a systematic review and meta-analysis. Ann Thorac Surg 2015; 99 (05) 1841-1847
• 24 Baird CW, Chávez M, Sleeper LA. et al. Reintervention rates after bioprosthetic pulmonary valve replacement in patients younger than 30 years of age: a multicenter analysis. J Thorac Cardiovasc Surg 2021; 161 (02) 345-362.e2