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J Thorac Cardiovasc Surg 2004;127:611
© 2004 The American Association for Thoracic Surgery

Letter to the editor

Reply to the Editor

Hôpital Necker-Enfantes Malades, Paris, France

We read with interest the comments by Zavanella and colleagues about the article we recently published in the Journal of Thoracic and Cardiovascular Surgery.¹ Although commonly used conduits are made of woven synthetic tubes as supportive housing for a biological valve, bovine jugular vein conduits (Contegra, Medtronic Inc, Minneapolis, Minn) are totally integrated and nonsupported, making these conduits easy to handle and suture. As mentioned by Zavanella and coworkers, although preliminary studies reported excellent durability of Contegra conduits,^2-5 various reports are now emerging that balance previous enthusiastic results. Classical conduit complications have been replaced by extensive intimal proliferation at the distal anastomosis, leading to the progressive dilatation of the proximal part of the conduit and to a severe valvular leak. This complication occurred in 3 of our patients at a mean interval of 4.3 months. One additional patient developed an inappropriate conduit dilatation 14 months after its insertion.⁶ Interestingly, it was a supported 14-mm conduit. Initially, we wrongly thought that the 2 external cloth-covered propylene rings added to provide additional support to the valve would avoid this type of complication. However, the rings were sufficient to prevent the apparition of a valvular leak but failed to preserve the integrity of the conduit. The mechanisms involved in the occurrence of extensive intimal proliferation are unknown. We have hypothesized that immunologic rejection, direct cytotoxicity of residual glutaraldehyde, chemical reaction between suture material and glutaraldehyde-fixed conduit, and cellular damage during suturing might be involved. Interestingly, Ishizaka and colleagues⁷ recently reported similar outcomes between the Contegra conduit and Shelhigh No-React porcine pulmonary valve conduit (Shelhigh Inc, Union, NJ), a new nonsupported conduit. Despite different animal origin and processing, these 2 different conduits share the same complications, emphasizing the role of immune response. Other factors listed previously might enhance the reaction initiated by host response.

In conclusion, as stated by Zavanella and colleagues, early and midterm complications of Contegra conduits should raise a note of caution on its use, in particular in neonates and infants. The risk of aneurysmal dilatation makes close echocardiographic follow-up mandatory in patients with unsupported as well as supported conduits.

	References

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1. Boudjemline Y, Bonnet D, Massih TA, Agnoletti G, Iserin F, Jaubert F, et al. Use of bovine jugular vein to reconstruct the right ventricular outflow tract: early results. J Thorac Cardiovasc Surg. 2003;126:490–497[Abstract/Free Full Text]
   
2. Bove T, Demanet H, Wauthy P, Goldstein JP, Dessy H, Viart P, et al. Early results of valved bovine jugular vein conduit versus bicuspid homograft for right ventricular outflow tract reconstruction. Ann Thorac Surg. 2002;74:536–541[Abstract/Free Full Text]
   
3. Carrel T, Berdat P, Pavlovic M, Pfammatter JP. The bovine jugular vein: a totally integrated valved conduit to repair the right ventricular outflow. J Heart Valve Dis. 2002;11:552–556[Medline]
   
4. Corno AF, Hurni M, Griffin H, Galal OM, Payot M, Sekarski N, et al. Bovine jugular vein as right ventricle-to-pulmonary artery valved conduit. J Heart Valve Dis. 2002;11:242–247[Medline]
   
5. Breymann T, Thies WR, Boethig D, Goerg R, Blanz U, Koerfer R. Bovine valved venous xenografts for RVOT reconstruction: results after 71 implantations. Eur J Cardiothorac Surg. 2002;21:703–710[Abstract/Free Full Text]
   
6. Boudjemline Y, Bonnet D, Agnoletti G, Vouhe P. Aneurysm of the right ventricular outflow following bovine valved venous conduit insertion. Eur J Cardiothorac Surg. 2003;23:122–124[Abstract/Free Full Text]
   
7. Ishizaka T, Ohye RG, Goldberg CS, Ramsburg SR, Suzuki T, Devaney EJ, et al. Premature failure of small-sized Shelhigh No-React porcine pulmonic valve conduit model NR-4000. Eur J Cardiothorac Surg. 2003;23:715–718[Abstract/Free Full Text]
   

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Boudjemline, Y. Articles by Sidi, D. Search for Related Content PubMed Articles by Boudjemline, Y. Articles by Sidi, D. Related Collections Valve disease Related Article