Construction and implantation of a modified trileaflet polytetrafluoroethylene valved conduit for pulmonary valve replacement

Objectives Handmade expanded polytetrafluoroethylene (ePTFE) valved conduits have emerged as a durable and cost-effective option for pulmonary valve replacement (PVR). We have reported excellent results of trileaflet ePTFE valved conduit and the longest follow-up exceeded 10 years. Technical precision during valve construction and implantation is critical to optimize valve function and conduit geometry, and we recently modified the technique. We report our updated technique and clinical outcomes. Methods The conduit was constructed intraoperatively on a sterile back table while the patient was being prepared by the anesthesia team. Leaflet dimensions were calculated based on conduit diameter, and leaflets were fashioned with 1 mm extensions at each end to reinforce commissural attachment, then sutured to an ePTFE tube graft using three CV-5 sutures with external knot tying. The graft was rotated during construction to ensure accurate leaflet alignment and valve competence was confirmed prior to implantation. During implantation, the main pulmonary artery was divided to optimize conduit geometry, minimizing the posterior conduit length and the graft trimmed in a trapezoidal fashion to reduce tension and improve alignment. Results Fifty-four patients received ePTFE valved conduit. Conduit sizes were 18 mm (n=7), 20 mm (n=9), 22 mm (n=1), 24 mm (n=36), and 28 mm (n=1). Median follow-up was 1.4 years (maximum 4.3 years). There was one mortality during follow up due to infectious pseudoaneurysm of the aortic root after Ross procedure. One patient developed severe pulmonary insufficiency after surgery. Recent echocardiography showed no significant pulmonary stenosis, pulmonary insufficiency, or valve deterioration in the remaining patients, and no catheter-based or surgical reinterventions have been required to date. Conclusions This refined technique for the construction and implantation of a trileaflet ePTFE valved conduit is simple, reproducible, and yields excellent early hemodynamic results. Attention to leaflet design, commissural security, and conduit geometry may contribute to low early failure rates and favorable valve performance. Longer-term follow-up is ongoing to assess durability.