Bovine pericardial versus porcine bioprosthetic valves in pulmonary position for adult congenital heart disease: A three-center, retrospective, propensity-weighted analysis of clinical outcomes.

INTRODUCTION AND OBJECTIVE: Adults with congenital heart disease affecting the right ventricular outflow tract often require repeated pulmonary valve replacements (PVR) throughout life, making prosthesis durability a critical determinant of long term outcomes. Bovine pericardial and porcine bioprosthetic valves are the most widely used in surgical PVR, yet comparative durability data remain inconsistent, partly due to reliance on nominal valve size rather than functional parameters. This study aimed to compare long term durability between both valves using indexed effective orifice area (iEOA) and analytic methods focused on prosthesis related performance. METHODS: We conducted a retrospective, multicenter observational study including pediatric and adult patients undergoing surgical PVR between 2013 and 2024 at three tertiary hospitals in Spain. The primary endpoint was a composite outcome of all cause mortality, reintervention, and structural valve deterioration. Propensity scores were constructed using clinically selected covariates and applied through inverse probability weighting (IPW). To isolate prosthesis related durability, survival was analysed by Cox regression model with left truncation at 1 year. RESULTS: A total of 231 patients were included (49.4% female; 64.1% with tetralogy of Fallot). Overall, 19.0% experienced a MACE during follow up, occurring at a median of 4.8 years after the truncation point. After IPW adjustment, baseline characteristics were well balanced. In the IPW adjusted Cox regression model, porcine prostheses were associated with a lower hazard of MACE (HR 0.37; 95% CI 0.16-0.83; p = 0.015). CONCLUSIONS: When early postoperative events are excluded and baseline differences minimized, porcine bioprostheses exhibit superior mid and long term durability compared with bovine pericardial valves.