Pulmonary homograft insertion after repair of pulmonary stenosis

Although the results of intracardiac repair for pulmonary stenosis or atresia are generally good, some patients develop symptoms due to to pulmonary regurgitation and right ventricular dilatation. Implantation of a pulmonary homograft may have a beneficial effect on these symptoms. Twenty-seven patients with symptoms due to pulmonary regurgitation and right ventricular dilatation were reoperated. The indication for surgery was dyspnea in 19, arrhythmia in five and both symptoms in three patients. The arrhythmia was supra-ventricular in four, ventricular in two and both supra-ventricular and ventricular in another two patients. A cryopreserved pulmonary homograft was implanted in the right ventricular outflow tract. Mean interval between intracardiac repair and homograft implantation was 15.6 years. Mean age at homograft implantation was 23.0 years. Concomitant procedures were performed in 18 patients. There were two early deaths (7%). Replacement of the homograft was necessary in one patient, 21 months after insertion. This patient had residual pulmonary stenosis immediately after surgery. On mid-term follow up (mean 36 months) all patients with dyspnea as indication for operation improved, except one with right and left ventricular dysfunction. Only two of eight patients with arrhythmia improved. On echocardiography, pulmonary regurgitation decreased in all patients. Right ventricular dilatation decreased in only 14 patients (52%). We conclude that pulmonary regurgitation after transannular patching can be treated with implantation of a cryopreserved pulmonary homograft with acceptable mortality and low morbidity. Clinical improvement results from reduction of the right ventricular volume overload rather than from decline in right ventricular dilatation. Arrhythmia as the only indication for operation is controversial.