Comparison of Extracellular Matrix Patch and Standard Patch Material in the Pulmonary Arteries

Evaluation and comparison of patch materials used for pulmonary arterioplasty in pediatric congenital heart surgery

Objective

To evaluate the long-term performance of the patch materials we have used to augment the pulmonary arterial tree across a wide spectrum of diagnoses and anatomical locations.

Methods

Retrospective, single-center review of 217 consecutive pediatric patients at a tertiary referral center from 1993 to 2020 who underwent patch arterioplasty of the pulmonary arterial tree from the pulmonary bifurcation to the distal pulmonary arterial branches. Reintervention data were collected and analyzed. Lesion-specific anatomy and other variables were analyzed as risk factors for reintervention.

Results

There were 280 total operations performed (217 initial operations and 63 reoperations) and 313 patches used. The patches used were autologous pericardium (166, 53.0%), pulmonary homograft (126, 40.3%), and a heterogeneous group of other materials (21, 6.7%). Overall patient survival was 86.2%, freedom from reoperation was 81.0% and freedom from reintervention (FFR) was 70.6%, with a median follow-up of 13.8 years (interquartile range, 6.3-17.9 years). For all patches, 10-, 20-, and 27-year FFR was 76.6%, 70.6%, and 70.6%, respectively. FFR was similar among all 3 patch type groups (P = .29). Multivariable Cox regression analysis showed that diagnoses of pulmonary atresia with ventricular septal defect and major aortopulmonary collateral arteries and hypoplastic left heart syndrome, patches placed at initial cardiac operation, and increasing number of cardiac operations were risk factors for reintervention.

Conclusions

Autologous pericardium and pulmonary homograft patches performed similarly. Although patch type conferred no difference in need for reintervention, other risk factors did exist. Namely, diagnoses of pulmonary atresia with ventricular septal defect and major aortopulmonary collateral arteries and hypoplastic left heart syndrome, patch placement at a patient's first cardiac operation, and increasing number of cardiac operations were risk factors for reintervention.

Patch Materials for Pulmonary Artery Arterioplasty and Right Ventricular Outflow Tract Augmentation: A Review

Patch augmentation of the right ventricular outflow tract (RVOT) and pulmonary artery (PA) arterioplasty are relatively common procedures in the surgical treatment of patients with congenital heart disease. To date, several patch materials have been applied with no agreed upon clinical standard. Each patch type has unique performance characteristics, cost, and availability. There are limited data describing the various advantages and disadvantages of different patch materials. We performed a review of studies describing the clinical performance of various RVOT and PA patch materials and found a limited but growing body of literature. Short-term clinical performance has been reported for a multitude of patch types, but comparisons are limited by inconsistent study design and scarce histologic data. Standard clinical criteria for assessment of patch efficacy and criteria for intervention need to be applied across patch types. The field is progressing with improvements in outcomes due to newer patch technologies focused on reducing antigenicity and promoting neotissue formation which may have the ability to grow, remodel, and repair.

Decellularized vs Non-decellularized Allogeneic Pulmonary Artery Patches for Pulmonary Arterioplasty

We studied pulmonary artery size, reinterventions, and panel reactive antibodies in patients with single-ventricle physiology who underwent a pulmonary arterioplasty with decellularized (DAPAP) and non-decellularized allogeneic pulmonary artery patches (non-DAPAP). Retrospective review identified 59 patients with single-ventricle physiology who underwent pulmonary arterioplasty from 2008 to 2017: 28 patients underwent arterioplasty with DAPAP and 31 patients with non-DAPAP. Demographic and operative variables were similar between groups. Among patients who underwent a Norwood procedure, a right ventricle to pulmonary artery shunt was more commonly used in the DAPAP group (12/20, 60%) and a modified Blalock-Taussig shunt was more commonly used in the non-DAPAP group (17/22, 77%). On multivariable analysis, the use of DAPAP was associated with higher pre-Fontan angiography Z-scores in right (estimate = 0.17, standard error = 0.04, P = 0.0005) and left pulmonary arteries (estimate = 0.12, standard error = 0.05, P = 0.01). No areas of calcification, discrete coarctation, or pulmonary dilation were noted in any of the pulmonary arteries. On multivariable analysis, the use of DAPAP was associated with higher freedom from pulmonary artery reinterventions (Hazard ratio = 0.36, 95% confidence interval = 0.13-0.9, P = 0.04). The median value for Class I panel reactive antibodies was 0% (IQR 0, 4) in the DAPAP and 23% (IQR 14, 36) in the non-DAPAP group. The median value for Class II panel reactive antibodies was 15% (IQR 0, 17) in the DAPAP and 21% (IQR 10, 22) in the non-DAPAP group. Pulmonary arterioplasty with DAPAP was associated with higher pre-Fontan pulmonary artery Z-scores and higher freedom from pulmonary artery reinterventions.

Over 400 Uses of An Intestinal Submucosal Extracellular Matrix Patch in a Congenital Heart Program

BACKGROUND

Repair of complex congenital heart disease frequently requires usage of a patch as an anatomical substitute. The study's aim is to evaluate the use, effectiveness and safety of utilizing small intestine submucosa extracellular matrix (SIS-ECM) patches in a congenital cardiac surgery program.

METHODS

This is a single-center, retrospective, cohort study of surgeries utilizing SIS-ECM between 2012-2019. The SIS-ECM data was categorized by usage and type (4-ply and 2-ply). All re-interventions/complications were reviewed by an independent surgeon, a practicing congenital heart surgeon and a pediatric cardiologist.

RESULTS

408 SIS-ECM patches were used in 309 patients (M/F=188/121; median age 8.5months). The usage consisted of 314 (77%) arterioplasties, 22 (5.4%) venoplasties, 63 (15.4%) intracardiac repairs, and 9 (2.2%) valve repairs. The most common usage was pulmonary artery repair (n=181; 44.4%). Median follow-up time was 3.9 years (range: 3days-7.4years). Ten (2.5%) patches required surgical (2 in first 30-days and 5 in 1^st year) and 27 (6.6%) required percutaneous re-interventions (2 in first 30-days and 22 in 1^st year). Between 4-ply (n=376) and 2-ply (n=32) SIS-ECM, rate of surgical (2.1% (n=8) vs 6.3% (n=2); p=0.18) or percutaneous re-interventions (6.4% (n=24) vs 9.4% (n=3); p=0.46) was not different. There were no deaths related to the SIS-ECM patch or reports of calcification.

CONCLUSIONS

SIS-ECM is a viable patch option that can be used in various cardiac and vascular reconstructive surgeries with low risk of failure and calcification. Long-term, positive outcomes may be maximized by consistent techniques and understanding appropriate applications of the patch.

Long-term Results Using Glutaraldehyde-treated Homograft Pericardium in Congenital Heart Surgery

BACKGROUND

This study reports the long-term outcomes using glutaraldehyde-treated cryopreserved homograft pericardium (CPH) in neonates, infants, children, and young adults undergoing congenital cardiac surgery.

METHODS

A retrospective review was performed of all patients at a single institution (Rady Children's Hospital, San Diego, CA) who had undergone surgical implantation with CPH between 2006 and 2016. The study identified 134 consecutive patients who underwent implantation of a total of 276 patches. The baseline demographic characteristics, primary cardiac diagnosis, surgical characteristics, operative reports, and postoperative catheterization and reoperation reports were analyzed. The use of CPH was categorized by specific anatomic insertion site.

RESULTS

The median age at patch implantation was 1.47 years (range, 1 day to 31.6 years). The numbers and locations of patch use were 124 for pulmonary arterial repair, 57 for repair of the aorta, 49 for septal repair, and 43 at other sites. At a median follow-up of 5.29 years, 9 patients had died (6.7%), but none of those deaths were related to CPH. Twelve patients (8.96%) underwent reoperations, and 18 patients (13.4%) underwent catheter interventions at sites of CPH implantation. The 10-year freedom from patch-induced reoperation and catheter intervention rates were 88.5% and 86.9%, respectively. Overall patch failure-free survival was 85.8% and 79.0% at 5 and 10 years, respectively.

CONCLUSIONS

The use of CPH patch in the surgical correction of congenital heart disease is effective and durable, as evidenced by the low reintervention rates. These results are comparable to the early and midterm outcomes of other similarly used surgical patches..

Comparison of Patch Materials for Pulmonary Artery Reconstruction

Various patch materials with variable cost are used for pulmonary artery reconstruction. An analysis of reintervention based on type of patch material might inform value-based decision making. This was a retrospective review of 214 sites of pulmonary artery reconstruction at a single center from 2000 to 2014. We excluded patients with unifocalization of aortopulmonary collaterals. Primary outcome was reintervention for each type of patch. Total number of patch sites was 214 (180 patients). Median follow-up was 3.7 years. Patch materials and number of sites were branch patch homograft (92), bovine pericardium (44), autologous pericardium (41), and porcine intestinal submucosal patch (37). Median age and weight at the time of patch reconstruction were 12.1 months and 8.5 kg. Reintervention occurred at 34 sites (15.9%). With Cox proportional hazards regression, the following variables were associated with reinterevention: preoperative renal failure - hazard ratio of 4.36 (1.87-10.16), P < 0.001 and weight at surgery - hazard ratio 0.93 (0.89-0.98), P = 0.004. Patch type was not related to reintervention (P = 0.197). Cost per unit patch ranged from $0 (dollars, US) for untreated autologous pericardium to $6,105 for homograft branch patch. In this retrospective analysis, there was no relationship between type of patch used for main or central branch pulmonary artery reconstruction and subsequent reintervention on that site. This finding, combined with the widely disparate costs of patches, may help inform value-based decision making.