Arq. Bras. Cardiol. vol.99 número6

Review Article

The Contegra Valved Bovine Conduit: A Biomaterial for the Surgical
Treatment of Congenital Heart Defects
Shi-MinYuan
Department of Cardiothoracic Surgery, The First Hospital of Putian, Teaching Hospital, Fujian Medical University, Putian, Fujian Province – China

Abstract
Contegra, a bovine jugular vein graft, has been widely
used as a preferable biomaterial in the surgical treatment
of congenital heart defects, especially as a conduit for the
right ventricular outflow tract reconstruction. This article
aims to make a comprehensive review on the clinical
outcomes of Contegra.
Reports of Contegra published since 2002 were
comprehensively retrieved, collected and analyzed.
There were 1718 Contegra, applied in 1705 patients. The sizes
of the conduits were 8-22 mm. The patients aged from newborn
to 74.5 years, prevailed by pediatrics. The primary diagnosis
was congenital heart defects in all cases, with Tetralogy of Fallot,
truncus arteriosus and pulmonary atresia being the first three
diagnoses, representing 25.6%, 16.7%, and 13.1%, respectively.
Contegra was used as a tube graft in the pulmonary position
in 1635 (95.9%) patients, as a monocuspid patch in 12 (0.7%), as
a graft in the position of the pulmonary valve or a monocusps in
40 (2.3%), and as an inferior vena cava-pulmonary artery conduit
in the Fontan procedure in 18 (1.1%) patients, respectively.
Conduit reimplantation was performed in 141 (8.3%) patients
33.8 ± 37 (8.6-106.8) months after the initial conduit insertion.
Conduit plasty was necessary in 6 (0.4%), and reintervention in
83 (4.9%) patients. Indications for conduit reimplantation included
severe stenosis of the distal anastomosis, pseudoaneurysm of the
proximal anastomosis and severe conduit regurgitation.
As for the good performance, availability and longevity,
Contegra is a biomaterial suitable for the right ventricular outflow
tract reconstruction and for patch repair for ventricular septal
defect, but not apt for Fontan procedure.

Introduction
Contegra, a bovine jugular vein graft, is a valved
xenograft conduit developed by Medtronic1. Limitation of

Keywords
Heart defects, congenital / surgery; bioprosthesis; vascular
grafting; tetralogy of Fallot / surgery; transplantation, heterologous.

Mailing Address: Shi-Min Yuan •
The First Hospital of Putian, Teaching Hospital, Fujian Medical University,
389, Longdejing Street, Chengxiang District, Postal Code 351100, Putian,
Fujian Province – China
E-mail: shi_min_yuan@yahoo.com
Manuscript received February 03, 2012; revised February 03, 2012;
accepted May 22, 2012.

1159

availability in quantity and sizes, actual conduit longevity
and patient survival of the homo- and otherwise xenografts
made the clinical utilization of Contegra grafts for the right
ventricular outflow tract reconstruction for the patients
with complex congenital defects possible2. Patients with
congenital heart defects requiring right ventricular outflow
tract reconstruction or other operations with the use of
Contegra are often very young. Majority of them were
newborns or infants with low body weight, and only
minority were adults3. These risk factors were inevitably
associated with the postoperative conduit problems,
including conduit stenosis, insufficiency and degeneration,
etc, hence leading to further catheter intervention,
reoperation, or even mortality4.
Materials and methods
Reports with a patient series of ≥10 cases, who received a
Contegra conduit published since 2002 were comprehensively
retrieved, collected and analyzed in terms of patients’
information, Contegra conduit size, surgical indications,
conduit dysfunction, conduit explantation, catheter
intervention, freedom from the postoperative events and
patient survival, etc.
Data were expressed in mean ± standard deviation and
student t test was used to evaluate intergroup differences.
p ≤ 0.05 was considered of statistical significance.

Results
Totally 33 reports with a patient series of ≥10 cases, who
received a Contegra conduit published since 2002 were
collected1-35. The reports included 1718 conduits, applied in
1705 patients. The sizes of 758 Contegra conduits that were
used for the surgical treatment of congenital heart defects
were recorded ranging between 8 and 22 mm. The size
distribution was depicted in Figure 1. The mean conduit sizes
were 14-20.4 mm from different reports16,17,20,31,32,35 (Figure 2).
The median sizes were reported to be 16 mm19, and 20 mm35.
Graft size ≤ 20 mm was utilized in 51.8% of the patients35.
Nine hundred and sixty-seven patients had their gender
expressed in the reports, including 474 (49.0%) males and
493 (51.0%) females, with an equivalent gender predominance.
The patients aged from newborn to 74.5 years. Of the
33 reports, pediatric patients were described in 9 (27.3%)
reports with 5 of them included purely infants, adult patients
were dealt with in 1 (3.0%), and both pediatrics and adults were
reported in 22 (66.7%), and patients’ ages were not mentioned
in 1 (3.0%) report.

Shi-MinYuan
Contegra valved bovine conduit

Review Article

Figure 1 - The sizes of 758 Contegra conduits

Figure 2 - The mean conduit sizes reported from different reports

Arq Bras Cardiol 2012;99(6):1159-1165

1160

Shi-MinYuan
Contegra valved bovine conduit

Review Article
The Contegra was used as a tube graft in the pulmonary
position in 1635 (95.9%) patients, of whom a patch closure
of the VSD using a segment from the same Contegra material
was done in 11 patients26. The Contegra was tailored as a
monocuspid valved transannular patch in 12 (0.7%)22, as a
tube graft in the position of the pulmonary valve for pulmonary
valve replacements and as a monocusp in 40 (2.3%)33, and as
an inferior vena cava-pulmonary artery conduit in the Fontan
procedure in 18 (1.1%) patients27, respectively.
The primary diagnosis was congenital heart defects in
all cases. Of the 1416 patients receiving a tube graft in the
pulmonary position, Tetralogy of Fallot, truncus arteriosus and
pulmonary atresia with ventricular septal defect were the first
three involved congenital heart defects, representing 25.6%,
16.7%, and 13.1%, respectively (Table 1).
The conduit insertion was a primary surgery in 1079 (63.3%),
with previous palliative or repair surgery in 584 (34.3%),
with previous interventional therapy in 42 (2.5%) patients,
respectively.
The patients were at a mean follow-up of 31.8 ± 21.1 (3- 74)
months (n = 26), and a maximal follow-up of 69.4 ± 44.6
(25-193.2) months (n = 24). The peak transconduit
pressure gradient was 14.1 ± 3.5 (8.5-36.5) mmHg (n = 6)
at discharge, and 18.7 ± 7.9 (10.4-20) mmHg (n = 17)
at follow-up. There was no significant difference in the
transconduit pressure gradient between discharge and
follow-up (p = 0.1872).
Contegra conduit reimplantation was performed in
141 (8.3%) patients 33.8 ± 37 (8.6-106.8) months after the
initial conduit insertion. Conduit plasty was necessary in
6 (0.4%), and reintervention to the conduit or to the pulmonary

arteries in 83 (4.9%) patients. The conduit reimplantation
was due to severe stenosis (excessive gradient) of the distal
anastomosis refractory to interventional treatment9,14,24,33,35,
(pseudo)aneurysm of the proximal anastomosis19, progressive
right ventricular dysfunction caused by severe conduit
regurgitation18,20,33, endocarditis11,35 or graft degeneration35.
During the follow-up period, conduit valve was absent
of regurgitation in 17.2-77.5% 6,9,13, trivially regurgitant
in 31- 79.4%9,13, mildly regurgitant in 24-58.3% 9,15, and
moderately regurgitant in 3.4-8.6% 13,21,23,24,31 patients,
respectively. Significant conduit dilation (DD% >30%) was
observed in 27.5% patients21.
There were 58 and 37 early and late deaths with an early
mortality of 3.4% and a late mortality of 2.2%. The mortality
were sometimes unrelated to the conduit 5,31,32, but caused
by septicemia and endocarditis11.
Freedoms from severe stenosis at the distal anastomosis,
catheter intervention, conduit reoperation, and reoperation
after intervention were satisfactory in several reports (Table 2).
The actuarial survival rate was 85.7% at 5 years23, 93.1% ±
3.6% at 6 years18, and 91.5% ± 2.3% at 8 years32.

Discussion
Clinical features
For the pulmonary position Contegra, it was orthotopic
when Ross procedure, replacement after a prior tetralogy of
Fallot or double outlet right ventricle repair was performed,
while it was heterotopic in truncus arteriosus repair, Rastelli
operation, and severe pulmonary atresia32. The Contegra has

Table 1 - The primary diagnosis or operation of 1416 patients receiving a Contegra material
Primary diagnosis or operation

Case (%)

Tetralogy of Fallot

362 (25.6)

Truncus arteriosus

236 (16.7)

Pulmonary atresia with ventricular septal defect

185 (13.1)

Conduit failure

168 (11.9)

Double outlet right ventricle with pulmonary stenosis

100 (7.1)

Tetralogy of Fallot + pulmonary atresia

58 (4.1)

Transposition of the great arteries with ventricular septal defect and pulmonary stenosis

58 (4.1)

Aortic disease

27 (1.9)

Pulmonary stenosis/insuficiency

19 (1.3)

Corrected transposition of the great arteries

14 (1.0)

Pulmonary atresia with intact septum

11 (0.8)

Tetralogy of Fallot + atrioventricular canal

3 (0.2)

Taussig-Bing anomaly

2 (0.1)

Rare complex abnormalities

6 (0.4)

Miscellaneous

17 (1.2)

Ross procedure

142 (10.0)

Rastelli procedure

1161

Arq Bras Cardiol 2012;99(6):1159-1165

8 (0.6)

Shi-MinYuan
Contegra valved bovine conduit

Review Article
been praised for its good subvalvular and valvular performance
with good freedom from explantation in comparison to
homografts (Table 3), however, supravalvular events may occur
in Contegra as well5.
Nevertheless, long-term follow-up revealed no calcification
in the Contegra conduit23. Contegra is a promising alternative
patch material for ventricular septal defect repair 26. The
potential relevant advantages of using the Contegra conduit
between the inferior vena cava and the pulmonary artery
were excellent off-the-shelf availability, large range of available
sizes, easy tailoring and suturing, no need for proximal or
distal extension, and presence of a valve27. The patent conduit
with the valve competency may support better pulmonary
forward flow27.
Freedom from conduit events and survival of Contegra
was satisfactory as described above. Rastan et al.20 reported
freedom from reoperation was 77.6% and 59.3% at 1 and
4 years for patients less than 1 year of age compared with
93.5% and 87.4% for patients older than 1 year of age. By
comparison, the actuarial freedom from reoperations was
90.7% at 7 years for Contegra conduits significantly superior
to the overall freedom from reoperations for cryopreserved

valved homografts (81.3%)24. Right ventricle to left ventricle
pressure ratio development and freedom from explantation/
redo were equal for the Contegra conduits and homografts3.
The 3-year freedom from replacement for in-conduit stenosis
was 96 ± 4% for the Contegra and 69 ± 8% for allograft28.
Conduit failure
Conduit dysfunction is defined as a peak conduit
gradient greater than 40 mm Hg or greater than 2+
regurgitation and conduit failure was defined as the need
for conduit replacement or the need for catheter lab conduit
reintervention16. Of the entire patient setting, 141 (8.3%)
patients required conduit reimplantation at 8.6-106.8
months after the initial conduit insertion. It illustrated that
Contegra showed good durability requesting an explantation
up to 106.8 months after the primary surgery.
However, some Contegra conduits had poor durability
and failed in as short as 8.6 months. Therefore, the standard
deviation of the conduit reimplantation interval was as long
as 37 months. Indications for conduit surgery were conduit
obstruction (n = 128), conduit regurgitation (n = 3), and a
combination of both (n = 6)29. Severe graft incompetence,

Table 2 - Freedoms from severe stenosis at the distal anastomosis, catheter intervention, conduit reoperation, and reoperation after
intervention of Contegra conduit
Freedom from

1-year

2-year

3-year

68 ± 610

49 ± 810

10018

Moderate stenosis (%)

10018

9218

8218

Severe regurgitation (%)

9718

8618

8118

18

18

6418

Severe stenosis at the distal
anastomosis (%)

Moderate regurgitation (%)
Conduit reoperation (%)
Catheter intervention (%)

91

80

98,318
98.5

18

3.5-year

93,1-9418,23
92.9

18

Reoperation after intervention (%)

66

20

5-year

6-year

7-year

9-year

10-year

78,3-9122,23,34

67,817

90,723

8930

63.534

71.4-80

22,31

48.2

17

10024

Table 3 - A comparison between Contegra and cryopreserved valved homografts
Variables

Contegra

Cryopreserved valved homografts

Trend of postoperative right ventricle to pulmonary artery
gradient14,23

Decreasing

Unchanging

Postoperative right ventricle to pulmonary artery mean gradient
(mmHg)23

19.8 ± 11.5

14.5 ± 11.2

Moderate valvular regurgitation (%)23

8.0

3.4

Supravalvar lesions23

No

No

Pliable to be calciied, moderate to
severe

None or mild

Calciication23,35
Reoperation for conduit dysfunction (%)23

6

16.1

Actuarial freedom from reoperations at 7 years (%)23

90.7

81.3

Successful at slowing subsequent gradient progression in children26

More

Less

A signiicant improvement

A more modest improvement

Successful catheter intervention in time-related progression of
peak RVOT gradient27

Arq Bras Cardiol 2012;99(6):1159-1165

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Contegra valved bovine conduit

Review Article
progressive supravalvular stenosis, or combined were
the main causes of conduit explantation after Contegra
implantation20. Distal anastomosis obstruction seemed to
be a major problem responsible for the reoperation for the
conduit early postoperatively31. Stenosis of the proximal
pulmonary arteries or diminutive pulmonary arteries was
also indicated for the conduit explantation of the Contegra,
in particular in pulmonary atresia and truncus arteriosus23.
Fibrous pannus formation at the distal anastomotic site or due
to thrombus formation leading to conduit obstruction was an
alternative condition requiring a conduit replacement23. It
was observed that gradients during follow-up were located
at the anastomotic site between the Contegra conduit and
the pulmonary arteries23.
Corno et al. 37 described that reoperation was nonconduit-related in all 26 cases included in their study.
Peri-conduit infection, abscess or endocarditis, was often
seen31. Structural deterioration of the Contegra graft may
be seen in small number of patients (5.1%)31. Necessity for
reoperations within the first 2 years was significantly lower
for Contegra grafts than for non-blood group compatible
cryopreserved homografts, 2 of 78 (2.6%) and 8 of
20 (40.0%), respectively33. Contegra grafts had reoperations
due to insufficiency in only 6%, however, reoperations were
mainly due to peripheral pulmonary stenosis at the distal
anastomosis and aneurysms34.
Graft valve regurgitation ≥3+ was associated with
age < 1 year at surgery, Contegra conduit size <14 mm, and
the right ventricle to left ventricle pressure ratio ≥ 0.64. The
rate of overall conduit replacement was 25% for the Shelhigh
pulmonic xenograft versus 26% for Contegra with a mean
time to replacement of 18 ± 9 months for the Shelhigh
pulmonic xenograft versus 42 ± 4 months for Contegra with
no significant difference (p = 0.25) 34.
Conduit valve stenosis
Dave et al. 32 reported that 28.2% of their 163 survivors of
Contegra implantation developed Contegra conduit stenosis,
of which 19.6% were at the proximal anastomotic, 32.6%
were at the valvular, and 47.8% at the distal anastomotic
level. Distal anastomosis stenosis with supravalvular conduit
dilation was also found a cause for conduit explanation14.
Corno et al.38 reported that postoperative intervention was
due to twisted or stenotic conduit in 2 of 5 patients. Rastan
et al.20 observed that stenosis at the distal anastomosis
occurred in 25% of their patients with a mean transconduit
gradient increased from 15 to 23 mmHg at follow-up.
When the Contegra was ring-supported, the transconduit
gradient became a bit elevated16. At 38-month follow-up,
mean pulmonary pressure gradient was 14.5 ± 7.9 mmHg
(Ross procedure: 14.1 ± 8.8 mmHg, Tetralogy of Fallot:
15.8 ± 6 mmHg , isolated pulmonary valve disease:
12.5 ± 3.5 mmHg, dilated cardiomyopathy: 10 mmHg,
double outlet right ventricle: 24 mmHg)30.
Conduit dilation
Dilation of the right ventricular outflow patch and conduit
may progress14,20. In an attempt to maintain conduit valve

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Arq Bras Cardiol 2012;99(6):1159-1165

geometry and competency, a ring-supported Contegra can be
an alternative. At the time of discharge and at follow-up, the
degree of conduit valve insufficiency and the gradient across
the conduit was not significantly different from the patients
who received non-ring-supported Contegra conduit16. In
the patients with severe regurgitation, Contegra structures
may change involving completely vanished valve leaflets
and rudiments of the commissures20. High right ventricle
to left ventricle pressure ratio, distal conduit stenosis 21,
and pulmonary artery branch obstruction or pulmonary
hypertension23. The grade of the graft valve regurgitation
did not change over time in some patients25. Interventions,
sometimes on an urgent basis, included the dilation and/
or stenting of the distal anastomosis in more patients, and
dilation occurred at the subvalvular level of the conduit, and
concomitant major aortopulmonary collateral arteries coil
occlusion in a few20.
Thrombosis
Thrombus formation at the distal anastomosis was one of
the indications for Contegra conduit explantation23. All three
patients with a Contegra conduit for total cavopulmonary
connection experienced serious complications of conduit
thrombosis, implying the thrombogenicity of the Contegra
and it was recommended not being used as a conduit for total
cavopulmonary connection38.
Basic research
Histologic examination of the explanted conduits
revealed excessive intimal peel formation forming an
annular membrane at the level of the distal anastomosis with
infiltrations of lymphocytes and macrophages11,14,20,34. Severe
perigraft scarring reaction was also observed14. Similar chronic
inflammatory reaction was also observed in the Contegra,
but not as strong as in the Shelhigh pulmonic xenograft
group34. The pathological changes were in line with the better
performance of the Contegra conduit. A computational fluid
dynamic study demonstrated more homogeneous pressure,
velocity and shear stress distributions for elliptical compared to
circular anastomosis at the pulmonary artery bifurcation, and
preferential flow in left pulmonary artery, suggesting that the
elliptical anastomosis with larger cross-sectional area than the
circular may reduce incidence and degree of distal stenosis,
particularly for small size conduits38.

Risk factors
Risk factors for


reoperation were age less than 1 year, correction
of truncus arteriosus, conduit size of 12 mm,
and persistently elevated right-ventricular-to-left
ventricular pressure ratio greater than 0.620;



percutaneous right ventricular outflow tract
reintervention were small conduit size 12 and 14 mm,
and truncus arteriosus correction, and right ventricle
to left ventricle pressure ratio in the immediate postoperative period20;

Shi-MinYuan
Contegra valved bovine conduit

Review Article


conduit stenosis were younger age, graft size and
indication, which did not change over time11;



pulmonary artery obstruction were younger age
(< 1 year) at operation and small graft size (< 14 mm)23;



valve regurgitation was always secondary to dilation
in the presence of severe distal stenosis11.

However, Tiete et al.13 did not observed any significant
correlation between younger age (≤ 6 months) or small graft
size (≤ 14 mm) and a gradient at the distal anastomosis after
implantation and at last follow-up, which was supported by
Schoenhoff et al.34. The multivariable analysis confirmed that
graft size ≤ 20 mm, the non-anatomical position of the graft,
and the use of the Contegra conduit were predictive of conduit
explantation35. Niemantsverdriet et al.29 noted Contegra
conduits and aortic homografts showed earlier failure than
pulmonary homografts, but the time to conduit failure could
be extended after transcatheter intervention.
In conclusion, right ventricular outflow tract reconstruction
with Contegra can result in better hemodynamics, longevity
and long-term survival than other biomaterials in most of the
situations of congenital heart defect repair. It can also be used
as a monocusp material in congenital heart defect repair.

However, it should be avoided using as an inferior vena
cava-pulmonary artery conduit in Fontan operation39. The
common risk factors younger age at operation, smaller size of
the conduits and higher right ventricle to left ventricle pressure
ratio that were in charge of the postoperative conduit events
including conduit dysfunction and the subsequent conduit
explantation and catheter intervention should be taken into
consideration in the decision-making of the surgical treatment.
In the operation, an elliptical anastomosis is preferred in order
to prevent anastomotic stenosis.
Potential Conflict of Interest
No potential conflict of interest relevant to this article
was reported.
Sources of Funding
There were no external funding sources for this study.
Study Association
This study is not associated with any post-graduation program.

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