Femoral vein homograft for neoaortic reconstruction in the Norwood stage 1 operation: A follow-up study

Objective: The aim of this study was to analyze our experience with the cryopreserved femoral vein homograft in comparison with standard biomaterials for neoaortic reconstruction in the Norwood stage 1 operation. Methods: All patients who underwent the Norwood operation from September 2004 to April 2011 were analyzed retrospectively (n = 107). Patients were grouped into group A(cryopreserved femoral vein homograft; n = 72) or group B (other; n = 35). Intergroup comparisons and dimensional analyses of all available angiograms were performed. Two surgical techniques, "standard homograft cuff" and "homograft tube," were compared. Results: Multivariable Cox regression analysis revealed use of biomaterial other than femoral vein (P = .01; hazard ratio, 3.0; 95% confidence interval [CI], 1.4-6.4), weight less than 2.5 kg at the time of stage 1 (P - .01; hazard ratio, 3.7; 95% CI, 1.7-7.8), and need for extracorporeal membrane oxygenator support after stage 1 (P < .001; hazard ratio, 13.8; 95% CI, 5.9-31.9) as significant independent predictors of overall mortality. Improved late survival at 48 months was seen with the femoral vein homograft compared with other biomaterials when a "homograft tube with end-to-side ascending aortic reimplantation technique" was used (group A [75%] vs group B [44%]; P = .03). With the use of the "homograft cuff technique," survival was similar for femoral vein homografts and other biomaterials (group A [67%] vs group B [61%]; P = .85). Similar neoaortic coarctation rates were seen in both groups (A: 25/59 [42%] vs B: 12/26 [46%]; P = .81). A progressive increase in the diameter of the neoaorta was seen over time in both groups with both technical modifications (tube grafts pre-stage 2 vs pre-stage 3: group A [10.61 mm +/- 1.93 vs 13.74 mm +/- 3.16] [P < .001] and group B [13.93 mm +/- 6.71 vs 17.38 mm +/- 5.92] [P = .049]); cuff repair pre-stage 2 to pre-stage 3: group A [13.98 mm +/- 2.13 vs 19.09 mm +/- 4.18] [P = .002] and group B [16.06 mm +/- 3.05 vs 19.73 mm +/- 2.93] [P < .001]). The neoaortic Z-scores were generous with the use of homograft cuffs and modest when homograft tubes were used and maintained in range over the follow-up time. Conclusions: Survivals are improved with the use of femoral vein homograft for neoaortic reconstruction for Norwood stage 1 operation, especially when used as a homograft tube with end-to-side aortic reimplantation. Femoral vein homografts have similar recoarctation rates compared with standard biomaterials. Progressive growth/dilation of the neoaorta in proportion to somatic growth is seen with femoral vein tube grafts.