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How to construct and implant expanded polytetrafluoroethylene (ePTFE) valved conduit
Abel F. Getachew1, Ashok Muralidaran2, Castigliano Bhamidipati2, Nikita Zadneulitca2, Yoshio Ootaki2
1School of Medicine, Oregon Health & Science University, Portland, OR, 2Oregon Health & Science University, Portland, OR
Background: 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 longest follow up exceeded more than 10 years. Technical precision during valve construction and implantation is critical to optimize valve function and conduit geometry, and we recently modified the technique. Hence, we report our modified technique and early clinical outcomes. Methods: Between 2022 and 2025, 50 consecutive patients underwent surgical PVR with a handmade trileaflet ePTFE valved conduit at our institution. Median age was 10.6 years (6 months to 37 years). The median body weight was 34.7 kg (6.7 kg to 140 kg). The conduit was constructed intraoperatively using a standardized technique. Leaflet size was calculated based on conduit diameter, and leaflets were cut to shape with a 1-mm "wing" extension at each end to reinforce commissural attachment. Leaflets were sewn to an ePTFE tube graft using CV-5 sutures, ensuring secure commissural fixation with all knots tied externally. The graft was flipped during construction to facilitate precise leaflet alignment and then flipped back before completion. Three vertical mattress commissural sutures were placed, and valve competence was tested before implantation.During implantation, the main pulmonary artery was divided to increase the effective distance between the right ventricle and pulmonary artery. Posterior distances were measured using silk sutures, and the commissure anticipated to experience the greatest mechanical stress and least tissue support was positioned posteriorly to minimize conduit length. The posterior aspect of the graft was asymmetrically trimmed with a shorter posterior edge than the anterior edge to optimize conduit geometry and reduce tension. Results: Median follow-up was 1.5 years (range, 0.3-3.2 years). Conduit sizes were 18 mm (n=6), 20 mm (n=8), 24 mm (n=35), and 28 mm (n=1). There was one late mortality unrelated to the conduit, due to pseudoaneurysm of the aortic root following a Ross procedure. One patient developed severe pulmonary insufficiency postoperatively. No other patients developed significant pulmonary stenosis or insufficiency, and no catheter-based or surgical reinterventions have been required to date. Conclusions: This refined technique for construction and implantation of a trileaflet ePTFE valved conduit is simple, reproducible, and associated with excellent early hemodynamic performance. Attention to leaflet design, secure commissural fixation, and optimized conduit geometry may contribute to low early failure rates and favorable valve function. Longer-term follow-up is ongoing to assess durability.
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