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J Thorac Cardiovasc Surg 2007;133:1101-1103
© 2007 The American Association for Thoracic Surgery

Brief Communication

Immunohistologic examination of pedicled autologous pericardium 9 years after implantation for an extracardiac conduit in Fontan pathway: Comparison with in situ pericardium and pulmonary arterial tissue from the same patient

Iki Adachi, MDa, Hatsue Ishibashi-Ueda, MDb, Toshikatsu Yagihara, MDa,*, Koji Kagisaki, MDa, Ikuo Hagino, MDa, Toru Ishizaka, MDa, Hideki Uemura, MD, FRCSc

a Department of Cardiovascular Surgery, National Cardiovascular Center, Suita, Japan
b Department of Pathology, National Cardiovascular Center, Suita, Japan
c Department of Cardio-Thoracic Surgery, Royal Brompton Hospital, London, UK.

Received for publication December 1, 2006; accepted for publication December 13, 2006.

* Address for reprints: Toshikatsu Yagihara, MD, 5-7-1 Fujishirodai, Suita, 565-8565, Japan. (Email: yagihara{at}hsp.ncvc.go.jp).


Figure 1
Dr Adachi


To date there have been no clinical reports, other than our own previous report,1Go describing the histopathology of implanted pedicled autologous pericardium. Even in that report, a concern remains regarding whether the findings could correctly reflect the intrinsic properties of this tissue, because the examined tissue had been situated in apparently abnormal circumstances in which a conduit constructed with the pericardium had been compressed and occluded. Fortunately, we obtained another pedicled specimen that had been quite functional in a Fontan pathway at the time of removal. The aim of this study was to confirm the histologic characteristics of the pedicled pericardium, comparing them with our previous findings.

Clinical Summary

The patient underwent primary Fontan operation with an extracardiac conduit made with pedicled autologous pericardial roll (PAPR).2,3Go at 1 year of age. At the operation, a small piece of pulmonary arterial tissue was obtained and adequately preserved for future histologic investigation. When the patient required reoperation to relieve subaortic stenosis at 10 years of age, pericardial specimens, including both the PAPR tissue and the fresh in situ pericardium on the diaphragmatic surface, were collected (Figure 1). Institutional approval for the study was obtained, and the patient and his parents gave informed consent for tissue removal and subsequent investigations. These specimens were examined immunohistologically.


Figure 1
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  		Figure 1. Intraoperative photograph: pericardial conduit and diaphragmatic surface of fresh pericardium were pink and pliable. Black dotted line indicates anastomotic site between pedicled autologous pericardial roll (PAPR) conduit and inferior vena cava (IVC); blue dotted circles indicate tissue sampling sites.

 
Elastica–van Gieson staining revealed a band of elastic tissue near the luminal surface of the PAPR tissue, whereas such a band was not observed at all in the fresh pericardial tissue. The elastic band was demonstrated more clearly in the pulmonary arterial tissue. The extent of microvasculature in the PAPR tissue shown on factor VIII staining was almost identical with that of the fresh pericardium. Staining for factor VIII also yielded positive cells, confirming the presence of endothelium on the luminal surface of the PAPR conduit (Figure 2). Neither calcification nor fibrosis was observed on hematoxylin–eosin staining.


Figure 2
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  		Figure 2. Elastica–van Gieson staining (original magnification x10) revealed band of elastic tissue near luminal surface of pedicled autologous pericardial roll tissue (upper middle) and pulmonary arterial tissue (upper right), whereas such elastic band was not observed at all in fresh pericardial tissue (upper left). Staining for factor VIII (original magnification x20) showed extent of microvasculature in pedicled autologous pericardial roll tissue (lower left) to be almost identical to that in fresh pericardial tissue (lower middle). Staining for factor VIII (original magnification x10) yielded positive cells, confirming presence of single layer of endothelial cells on luminal surface of pedicled autologous pericardial roll conduit (lower right).

 
Discussion

The largest difference between the previous study and this one is the situation in which the PAPR tissue was obtained. Obviously, when attempting to elucidate natural properties of some tissues, it is better to use tissues from a normal situation. In this regard, the specimen in this study is of particular value.

In our previous report,1Go we demonstrated four major findings: (1) preservation of microvasculature, (2) presence of a band of elastic tissue, (3) presence of endothelium on the luminal surface, and (4) absence of either calcification or fibrosis in the PAPR tissue. Of these, preservation of microvasculature is of significant importance with respect to growth ability, because tissue viability is a fundamental element for growth. In this study, both presence and equivalent density of the microvasculature were demonstrated by comparison with the fresh in situ pericardial tissue. As we described previously,1Go the density is clearly greater than that in the implanted, nonpedicled pericardium. Preserved microvasculature and glossy appearance of the PAPR conduit can reasonably be considered to be the result of maintenance of pericardial pedicle and to indicate preservation of viability.

Such comparison between the two different pericardial tissues was also useful when evaluating the extent of the band of elastic tissue. As shown in the photograph of the pulmonary arterial tissue, such a band is generally found in the vascular wall tissue, not in the normal pericardium. The layer of the developed elastic band in the PAPR tissue would suggest remodeling of the channel wall, in which the pedicled pericardium has transformed from its norm to the structure of the vascular wall after having been used for that purpose. The remaining two original findings (presence of endothelium and absence of calcification and fibrosis) were also confirmed in this study. Considering these findings together, PAPR seems to be a suitable material as a vascular substitute, at least for a low-pressure chamber such as the Fontan pathway.

In conclusion, the PAPR remained viable and even had obtained some characteristics similar to vascular wall 9 years after implantation for the Fontan pathway.

Acknowledgments

We thank Dr Yusuke Shimahara for his contribution in the intraoperative photograph.

References

  1. Adachi I, Yagihara T, Ishibashi-Ueda H, Kitamura S. Immunohistological findings for an extracardiac conduit in Fontan pathway constructed with pedicled autologous pericardium. Eur J Cardiothorac Surg 2006;29:1059-1060.[Abstract/Free Full Text]
  2. Uemura H, Yagihara T, Kawahira Y. The extracardiac Fontan procedure using a pedicled pericardial roll without cardiopulmonary bypass. J Thorac Cardiovasc Surg 1999;117:1046-1047.[Free Full Text]
  3. Adachi I, Yagihara T, Kagisaki K, Hagino I, Ishizaka T, Koh M, et al. Fontan operation with a viable and growing conduit using pedicled autologous pericardial roll: serial changes in conduit geometry. J Thorac Cardiovasc Surg 2005;130:1517-1522.[Abstract/Free Full Text]




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