Stylized heart with a composite graft seamlessly integrated, symbolizing growth and stability.

Valve Innovations: How a Composite Graft Can Impact Heart Surgery Outcomes

Avery Sinclair in Health & Wellness November 2025 • 5 min read.

"Discover how a composite valved RV-PA graft impacts pulmonary artery growth and patient stability after Stage 1 Palliation."

Congenital heart defects, particularly those requiring staged surgical palliation, present unique challenges in pediatric cardiology. One such challenge is optimizing pulmonary artery (PA) growth in patients with univentricular hearts undergoing Stage 1 Palliation (S1P), a procedure designed to improve blood flow to the lungs. The right ventricular to pulmonary artery shunt (RVPAS) is a common technique used in S1P, but it has been associated with suboptimal PA development, leading to the need for further interventions.

To address these limitations, surgeons have explored various modifications to the RVPAS, including the use of valved homografts—tissue grafts from human donors—in place of or in combination with synthetic conduits. The rationale behind this approach is that a valved conduit might reduce retrograde blood flow during diastole, potentially promoting better PA growth and reducing right ventricular volume overload. Some studies have suggested promising results with valved homografts, but the evidence remains varied, with some reports showing significant improvements and others finding no substantial difference.

A recent study, published in The Annals of Thoracic Surgery, delves into the impact of a composite RVPAS graft incorporating a valved femoral or saphenous vein homograft in patients undergoing S1P. This research aims to provide clarity on whether this specific graft configuration can improve postoperative hemodynamics, reduce the need for reinterventions, enhance PA growth, and improve overall survival. This article breaks down the findings of this study, offering insights into the potential benefits and drawbacks of this surgical technique, and what it means for patients and their families.

The Composite Graft Study: A Closer Look

Stylized heart with a composite graft seamlessly integrated, symbolizing growth and stability.

The study, led by David M. Hoganson and colleagues at Boston Children's Hospital, retrospectively reviewed data from 94 infants who underwent S1P with an RVPAS between January 2013 and May 2017. The patients were divided into three groups based on the type of RVPAS they received: a ring-reinforced polytetrafluoroethylene (PTFE) graft, a composite graft with a distal valved femoral vein homograft, or a composite graft with a distal valved saphenous vein homograft. The researchers then compared various outcomes, including postoperative hemodynamics, time to reintervention, PA growth, and survival rates.

One of the key findings was that patients who received the femoral vein homograft exhibited slightly better perioperative stability. Specifically, their arterial oxygen saturation was 2.3% higher, and their serum lactic acid levels were 1.24 mg/dL lower compared to the PTFE-only group. These improvements suggest that the valved homograft may help to optimize oxygen delivery and reduce tissue hypoxia in the immediate postoperative period. However, venous oxygen saturation was similar across all groups, indicating that the overall balance of oxygen supply and demand was not significantly altered.

Femoral Vein Homograft Benefit: Improved early post-operative stability.
Saphenous Vein Homograft Drawback: Increased risk of reintervention.
Pulmonary Artery Growth: No significant difference across graft types.
Survival Rates: Similar across all groups studied.

Interestingly, the type of homograft used appeared to influence the time to reintervention. The study found that 50% of patients with the saphenous vein homograft required a reintervention within 60 days, compared to only 5% of those with the PTFE graft and 12% with the femoral vein homograft. This suggests that saphenous vein homografts may be more prone to early failure or obstruction, necessitating earlier intervention. At the time of Stage 2 Palliation, there were no significant differences in pulmonary artery size, growth, or density of aortopulmonary collaterals. The 12-month survival rates were also similar across all three groups.

Clinical Implications and Future Directions

This study provides valuable insights into the use of composite valved RVPAS grafts in S1P. While the femoral vein homograft may offer some advantages in terms of early postoperative stability, it does not appear to substantially improve long-term PA growth or reduce the need for reinterventions. The saphenous vein homograft, on the other hand, may be associated with a higher risk of early reintervention. These findings underscore the importance of careful patient selection and graft selection when considering this surgical approach. More research is needed to determine the optimal graft configuration and to identify patient subgroups that may benefit most from this technique.

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This article is based on research published under:

DOI-LINK: 10.1016/j.athoracsur.2018.05.068, Alternate LINK

Title: Impact Of A Composite Valved Rv-Pa Graft After Stage 1 Palliation

Subject: Cardiology and Cardiovascular Medicine

Journal: The Annals of Thoracic Surgery

Publisher: Elsevier BV

Authors: David M. Hoganson, Claire L. Cigarroa, Sarah J. Van Den Bosch, Lynn A. Sleeper, Ryan Callahan, Kevin G. Friedman, Christopher W. Baird, Luis G. Quinonez, Aditya K. Kaza, Sitaram E. Emani, John N. Kheir

Published: 2018-11-01

Everything You Need To Know

What is Stage 1 Palliation (S1P) and how does the composite valved RVPAS graft aim to improve outcomes for infants with congenital heart defects?

Stage 1 Palliation (S1P) is a surgical procedure performed on infants with univentricular hearts to improve blood flow to the lungs. The right ventricular to pulmonary artery shunt (RVPAS) is a common technique used in S1P, but it often results in suboptimal pulmonary artery (PA) development, necessitating further interventions. The composite valved RVPAS graft, which uses a valved homograft, is being explored as a modification to address these limitations, aiming to promote better PA growth and reduce right ventricular volume overload. However, its effectiveness is still under investigation.

In this study, what specific types of RVPAS grafts were compared and what outcomes were analyzed to assess their impact?

The study compared three groups of infants who underwent Stage 1 Palliation (S1P) with an RVPAS: those receiving a ring-reinforced polytetrafluoroethylene (PTFE) graft, a composite graft with a distal valved femoral vein homograft, and a composite graft with a distal valved saphenous vein homograft. Researchers analyzed postoperative hemodynamics, time to reintervention, pulmonary artery (PA) growth, and survival rates to determine the impact of each graft type.

What benefits were observed with the use of the femoral vein homograft in terms of postoperative stability, and what does this suggest about its potential impact?

The femoral vein homograft showed slightly better perioperative stability, with higher arterial oxygen saturation and lower serum lactic acid levels compared to the PTFE-only group. This suggests that the valved homograft may enhance oxygen delivery and reduce tissue hypoxia immediately after surgery. However, venous oxygen saturation was similar across all groups, indicating no significant difference in the overall balance of oxygen supply and demand.

What risks were associated with the saphenous vein homograft in this study, and how did it compare to the other graft types in terms of reintervention rates and overall survival?

The saphenous vein homograft was associated with a higher risk of early reintervention; 50% of patients required reintervention within 60 days, compared to 5% with the PTFE graft and 12% with the femoral vein homograft. This suggests that saphenous vein homografts may be more prone to early failure or obstruction. At the time of Stage 2 Palliation, there were no significant differences in pulmonary artery size, growth, or density of aortopulmonary collaterals. The 12-month survival rates were also similar across all three groups.

What are the clinical implications of this research on composite valved RVPAS grafts, and what future directions are recommended to further optimize this surgical technique?

While the femoral vein homograft may offer some advantages in terms of early postoperative stability, it does not significantly improve long-term pulmonary artery (PA) growth or reduce the need for reinterventions. The saphenous vein homograft may increase the risk of early reintervention. Further research is needed to optimize graft configuration and identify patient subgroups that may benefit most from this technique. Future directions could include longer-term follow-up studies and exploration of novel graft materials or designs. Additionally, personalized approaches based on individual patient anatomy and physiology may improve outcomes.