How long the Artificial Graft Used in Total Cavopulmonary Connection is Durable? - More than 10 Years Evaluation
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Objective: Artificial grafts have been used for an inferior vena caval (IVC) channel in total cavopulmonary connection (TCPC). The use of the artificial graft has a possible disadvantage about the lack of growth ability and progressive narrowing. We evaluated the long-term morphological changes of the artificial grafts used in TCPC. The effects of anti-coagulation therapy on the morphological changes of the graft were also evaluated. Methods: From 1987 to 1996, we performed TCPC in 125 patients. Artificial grafts (ePTFE tubes) were used as intra-atrial grafts in 63 patients. We performed cardiac catheterization at 1-year, 5-year and 10-year after TCPC in 32 patients who have more than 10-year follow-up period after surgery. Out of 32 patients, 8 patients underwent cardiac catheterization at 15-year after TCPC. The graft size ranged from 14mm to 22mm (14mm: 1, 16mm: 16, 18mm: 10, 20mm: 4, 22mm: 1). One year after TCPC, the cross-sectional area at the narrowest portion of the graft was calculated by biplane angiography. The area was also calculated at the same portion on the subsequent catheterization. Graft area / normal right pulmonary arterial area ratio (graft area / n-RPA area ratio) was also evaluated. To assess the effects of anti-coagulation therapy, 32 patients were divided into warfarin group (n=6: Warfarin was used throughout the follow-up period.), anti-platelet agent group (n=17: Anti-platelet agents were used throughout the follow-up period.) and anti-coagulation free group (n=9). The changes of the graft area were evaluated among 3 groups.
Results: There was no patient who required the replacement of the graft due to overgrowth or progressive graft stenosis. The cross sectional area of the graft was basically unchanged throughout the follow-up period up to 15 years. Significant increase was observed between 5 and 10-year. Warfarin, anti-platelet agent and anti-coagulation free groups had the same changes of the graft area. There were no significant differences among 3 groups. At 15-year follow-up, graft area / n-RPA area ratio decreased to 0.52±0.12, however, no patient had significant stenosis at the IVC channel.
Conclusions: The artificial graft used in Fontan circulation did not show progressive narrowing over 10-year follow-up. Anti-coagulation therapy did not affect the morphological changes of the graft. In Fontan circulation which has relatively low cardiac out put and non-pulsatile pulmonary blood flow, artificial grafts should be durable even in grown-up patients.
Changes of the Graft Area | 1-year | 5-year | 10-year | 15-year |
| Graft Area (mm2) | 129 +/- 39 | 127 +/- 38 | 134 +/- 36* | 149 +/- 39 |
| Graft Area: Warfarin group | 136 +/- 61 | 137 +/- 58 | 145 +/- 55 | |
| Graft Area: Anti-platelet agent group | 123 +/- 39 | 121 +/- 36 | 127 +/- 31* | |
| Graft Area: Anti-coagulation free group | 136 +/- 25 | 131 +/- 27 | 141 +/- 30* | |
| Graft Area / n-RPA area ratio | 1.04 +/- 0.36 | 0.72 +/- 0.46* | 0.59 +/- 0.18* | 0.52 +/- 0.12 |
| *: P<0.05 compared to the value on previous cathetelization |
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