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Eur J Cardiothorac Surg 2003;24:850-851
© 2003 Elsevier Science NL

Letter to the Editor

Surprising outcome similarities between Contegra^® bovine jugular vein conduit and Shelhigh No-React^® porcine pulmonary valve conduit: role of immunologic reaction

Pediatric Cardiology, Necker Hospital for Sick Children, 149 rue de Sèvres, 75015 Paris Cedex, France

Received 22 June 2003; accepted 9 August 2003.

^* Corresponding author. Tel.: +33-1-44-49-45-89; fax: +33-1-44-49-57-24
e-mail: younes.boudjemline{at}nck.ap-hop-paris.fr

Key Words: Pulmonary valved conduit • Contegra^® bovine jugular vein graft • Shelhigh No-React^® porcine pulmonary valve conduit • Right ventricular outflow tract reconstruction

We have read with interest the paper written by Ishizaka et al. [1]. Limited availability of small sized pulmonary homografts has led to the use of xenografts. Commonly used conduits are not ideal in terms of longevity, handling and growth potential. Therefore, new conduits, namely Shelhigh No-React^® porcine pulmonary valve conduit (Shelhigh Inc., Millburn) and Contegra^® bovine jugular vein (Medtronic Inc.), have recently been introduced. While commonly used conduits are made of woven synthetic tubes as supportive housing for a biological valve, Contegra^® and Shelhigh No-React^® conduits are totally integrated and non-supported. Preliminary animal and human studies have reported excellent durability [2,3]. However, reports are emerging that balance previous enthusiastic results [4,5]. Classical complications, namely focal valvular stenosis, conduit kinking, sternal compression, and diffuse stenosis by a panus ingrowth, have been replaced by extensive intimal proliferation at the distal anastomosis. In the case of unsupported conduits, this severe distal obstruction can lead to proximal aneurysmal dilation of the conduit. The generated valve leak adds a volume load resulting in right ventricular dysfunction. The mechanisms involved in conduit failure are unknown. However, despite different animal origin and processing, Contegra^® and Shelhigh No-React^® conduits share the same complications. The similarity of outcomes is questionable and emphasizes, in our opinion, the role of immune response. Host inflammatory reaction not found at the time of conduit retrieval probably initiates the inappropriate intimal proliferation. Additional factors such as endothelial lesions made during conduit suture, residual glutaraldehyde release from the implant, and shear stress related to hemodynamic local condition might amplify this reaction. Genetic factors might also interfere and explain why some individuals do not exhibit this kind of complication. Interestingly, with ‘classical conduits’, biological tissue was limited to the valve itself. Host reaction was directed against the valve leading to its destruction and calcification. Resulting obstruction was not followed by aneurysm of the proximal part because of the supportive role of the synthetic material. With newly available conduits, the entire conduit is subject to immunologic reaction as pointed out by the existence of an obstruction throughout the conduit in Ishizaka et al.'s report [1]. We never experienced such extensive obstruction with the Contegra^® conduit probably because the pseudo-intimal proliferation in the distal anastomosis rapidly led to dilatation of the proximal part. Structural differences between bovine jugular vein and porcine pulmonary artery where pressure is usually higher probably account for this different feature.

Thrombus formation is another difference between these two conduits. We have experienced, not unusually, the formation of thrombi inside leaflets with the Contegra^® conduit. Ishizaka et al. did not report such a complication [1]. This could be related to the different valve process in the Shelhigh^® conduit.

In conclusion, failure of the Contegra^® and Shelhigh^® conduits is very similar, emphasizing the potential role of the host immunologic reaction. The risk of aneurysmal dilatation of the proximal part of the conduit makes close echocardiographic follow-up mandatory especially when using small sizes.

References

1. Ishizaka T., Ohye R.G., Goldberg C.S., Ramsburg S.R., Suzuki T., Devaney E.J., Bove E.L. 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]
2. Breymann T., Thies W.R., 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]
3. Marianeschi S.M., Iacona G.M., Seddio F., Abella R.F., Condoluci C., Cipriani A., Iorio F.S., Gabbay S., Marcelletti C.F. Shelhigh No-React porcine pulmonic valve conduit: a new alternative to the homograft. Ann Thorac Surg 2001;71:619-623.[Abstract/Free Full Text]
4. 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]
5. Boudjemline Y., Bonnet D., Abdel Massih T., Agnoletti G., Iserin F., Jaubert F., Sidi D., Vouhe P. Use of bovine jugular vein to reconstruct the right ventricular outflow tract: early results. J Thorac Cardiovasc Surg 2003.

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