Time-Related Risk of Pulmonary Conduit Re-replacement: A Congenital Heart Surgeons’ Society Study

Background: Patients receiving a right ventricle to pulmonary artery conduit (PC) in infancy will require successive procedures or replacements, each with variable longevity. We sought to identify factors associated with time-related risk of a subsequent surgical replacement (PC3) or transcatheter pulmonary valve insertion (TPVI) after a second surgically placed PC (PC2). Methods: From 2002 to 2016, 630 patients from 29 Congenital Heart Surgeons’ Society member institutions survived to discharge after initial valved PC insertion (PC1) at age ≤ 2 years. Of those, 355 underwent surgical replacement (PC2) of that initial conduit. Competing risk methodology and multiphase parametric hazard analyses were used to identify factors associated with time-related risk of PC3 or TPVI. Results: Of 355 PC2 patients (median follow-up, 5.3 years), 65 underwent PC3 and 41 TPVI. Factors at PC2 associated with increased time-related risk of PC3 were smaller PC2 Z score (hazard ratio [HR] 1.6, P <.001), concomitant aortic valve intervention (HR 7.6, P =.009), aortic allograft (HR 2.2, P =.008), younger age (HR 1.4, P <.001), and larger Z score of PC1 (HR 1.2, P =.04). Factors at PC2 associated with increased time-related risk of TPVI were aortic allograft (HR: 3.3, P =.006), porcine unstented conduit (HR 4.7, P <.001), and older age (HR 2.3, P =.01). Conclusions: Aortic allograft as PC2 was associated with increased time-related risk of both PC3 and TPVI. Surgeons may reduce risk of these subsequent procedures by not selecting an aortic homograft at PC2, and by oversizing the conduit when anatomically feasible.