Late results of the peel operation for replacement of failing extracardiac conduits

Background. Pulmonary ventricle to pulmonary artery conduits have made repairing many complex congenital cardiac anomalies possible. Late patient outcome is adversely affected by the hemodynamic consequences of conduit failure and the need for reoperation for conduit replacement. Methods. We retrospectively reviewed 102 patients (65 males, 37 females) who underwent operation with autologous tissue reconstruction ("peel operation") between May 1983 and November 2001, in which a prosthetic roof was placed over the fibrous bed of the explanted conduit. Ages ranged from 5 to 58 years old (median age 19 years old). Explanted conduits were Hancock (n = 54), homograft (n = 21), Tascon (n = 11), and other (n = 16). The conduit roof was constructed with pericardium (n = 91) and other (n = 11). A prosthetic pulmonary valve was utilized in 68 patients: porcine in 65 patients and mechanical in 3 patients. A nonvalved reconstruction was performed in 34 patients. Concomitant cardiac procedures were performed in 66 patients. Results. Early mortality overall was 2% (n = 2) and was 0% for patients who underwent isolated conduit replacement (n = 36). Mean follow-up was 7.6 years (maximum, 19 years). Overall survival at 10 and 15 years was 91% (84.7, 97.2) and 76% (62.8, 91.7), respectively. Nine patients required reoperation related to the peel operation: regurgitation in nonvalved conduit (n = 7); moderate pulmonary bioprosthesis stenosis and regurgitation with atrial arrhythmia (n = 1); and pulmonary bioprosthesis endocarditis (n = 1). Overall survivorship free of reoperation for peel reconstruction failure at 10 and 15 years was 90.7% (82.6, 99.6) and 82% (69.4, 97.0), respectively. Survivorship free of reoperation for patients with a prosthetic valve was 93.7%, and for those with no prosthetic valve was 80.0% at 15 years (p = 0.57). At late follow-up, 89% of patients were in New York Heart Association functional class I or II. Conclusions. The peel operation simplifies conduit replacement, can be performed with low risk, and provides a generous-sized flow pathway. In our experience late results demonstrate a lower freedom from reoperation than conventional prosthetic or homograft conduits.