1
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Albrahimi E, Korun O. Contemporary management of borderline left ventricle. Eur J Cardiothorac Surg 2024; 66:ezae247. [PMID: 38913849 DOI: 10.1093/ejcts/ezae247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 03/30/2024] [Accepted: 06/21/2024] [Indexed: 06/26/2024] Open
Abstract
Borderline left ventricle cases present considerable difficulties in determining the most effective surgical approaches. The evolution of approaches in the field has shifted from classical systemic pulmonary shunts to orthodox univentricular palliation and has subsequently seen the emergence of biventricular repair concepts. The concept of biventricular repair for borderline left heart conditions has developed through studies that aim to establish predictive scoring systems for identifying appropriate candidates. Despite continuous efforts, a definitive scoring system for guiding this decision is still difficult to find. There is a growing trend to provide neonatal patients with borderline ventricles with options other than univentricular palliation. Several centres have developed personalized strategies, including hybrid and staged ventricular recruitment approaches. These strategies provide sufficient time for personalized decision-making, taking into account the individual circumstances of each patient. This article presents an overview of the changing approaches to borderline left ventricular cases. It discusses the use of predictive scoring systems and emphasizes the advancements in staged strategies that improve the likelihood of successful biventricular repairs.
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Affiliation(s)
- Ergida Albrahimi
- Department of Cardiovascular Surgery, İstanbul University Cerrahpasa, Cerrahpasa Medical Hospital, Istanbul, Turkey
| | - Oktay Korun
- Department of Cardiovascular Surgery, İstanbul University Cerrahpasa, Cerrahpasa Medical Hospital, Istanbul, Turkey
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2
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Andersen ND, Overbey DM, Prabhu NK, McCrary AW, Sherwin JI, Allareddy V, Turek JW. Staged repair of borderline hypoplastic heart disease with early biventricular conversion. JTCVS Tech 2024; 24:150-163. [PMID: 38835569 PMCID: PMC11145415 DOI: 10.1016/j.xjtc.2024.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 01/15/2024] [Accepted: 02/07/2024] [Indexed: 06/06/2024] Open
Abstract
Objective In select patients with borderline ventricular hypoplasia, we adopted a strategy of initial single-ventricle palliation followed by staged or direct biventricular conversion by 2 years of age. Methods Between 2018 and 2023, 14 newborns with borderline hypoplastic heart disease deemed high risk for primary biventricular repair underwent palliative procedures as a neonate/infant, followed by staged or direct biventricular conversion. Results Of the 14 patients, 6 had borderline left ventricles and 8 had borderline right ventricles. Index neonatal operations were performed in 12 patients and included the Norwood operation (n = 5), pulmonary artery band (n = 3), ductal stent (n = 3), and hybrid Norwood (n = 1). Five patients underwent direct biventricular conversion, and the remaining 9 patients underwent staged ventricular recruitment operations at a mean age of 6 months (range, 3-11 months). Ventricular recruitment operations included atrial septation with or without ventricular rehabilitation, atrioventricular valve repair, or outflow tract operations. At a mean duration of 8 months (range, 4-10 months) after ventricular recruitment, there was a significant increase in chamber volume, aortic valve, and mitral valve size in patients with borderline left ventricles, and a normalization of the right ventricle:left ventricle end-diastolic volume ratio in patients with borderline right ventricles. To date, 13 of 14 patients have undergone successful biventricular conversion at a mean age of 16 months (range, 4-31 months). Conclusions In select newborns with borderline hypoplastic heart disease, single-ventricle palliation followed by staged or direct biventricular conversion may increase infant survival while allowing for early attainment of a biventricular circulation.
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Affiliation(s)
- Nicholas D. Andersen
- Department of Cardiothoracic Surgery, University of Texas Southwestern and Children's Health, Dallas, Tex
| | - Douglas M. Overbey
- Department of Surgery, Duke Children's Pediatric & Congenital Heart Center, Duke Children's Hospital, Durham, NC
| | - Neel K. Prabhu
- Department of Surgery, Duke Children's Pediatric & Congenital Heart Center, Duke Children's Hospital, Durham, NC
| | - Andrew W. McCrary
- Department of Pediatrics, Duke Children's Pediatric & Congenital Heart Center, Duke Children's Hospital, Durham, NC
| | - Jennifer I. Sherwin
- Department of Pediatrics, Duke Children's Pediatric & Congenital Heart Center, Duke Children's Hospital, Durham, NC
| | - Veerajalandhar Allareddy
- Department of Pediatrics, Duke Children's Pediatric & Congenital Heart Center, Duke Children's Hospital, Durham, NC
| | - Joseph W. Turek
- Department of Surgery, Duke Children's Pediatric & Congenital Heart Center, Duke Children's Hospital, Durham, NC
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3
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Liddle D, Gearhart A, Sleeper LA, Lu M, Feins E, Schidlow DN, Ghelani S, Powell AJ, Emani S, Beroukhim RS. Mitral valve orifice area predicts outcome after biventricular repair in patients with hypoplastic left ventricles. J Cardiovasc Magn Reson 2024; 26:101029. [PMID: 38403073 PMCID: PMC10965470 DOI: 10.1016/j.jocmr.2024.101029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 02/20/2024] [Indexed: 02/27/2024] Open
Abstract
BACKGROUND Identification of risk factors for biventricular (BiV) repair in children with hypoplastic left ventricles (HLV) has been challenging. We sought to identify preoperative cardiovascular magnetic resonance (CMR) predictors of outcome in patients with HLVs who underwent BiV repair, with a focus on the mitral valve (MV). METHODS Single-center retrospective analysis of preoperative CMRs on patients with HLV (≤50 mL/m2) and no endocardial fibroelastosis who underwent BiV repair from 2005-2022. CMR measurements included MV orifice area in diastole. The primary composite outcome included time to death, transplant, BiV takedown, heart failure admission, left atrial decompression, or unexpected reoperation; and the secondary outcome included more than or equal to moderate mitral stenosis and/or regurgitation. RESULTS Median follow-up was 0.7 (interquartile range 0.1, 2.2) years. Of 122 patients [59 atrioventricular canal (AVC) and 63 non-AVC] age 3 ± 2.8 years at the time of BiV repair, freedom from the primary outcome at 2 years was 53% for AVC and 69% for non-AVC (log rank p = 0.12), and freedom from the secondary outcome at 2 years was 49% for AVC and 79% for non-AVC (log rank p < 0.01). Independent predictors of primary outcome for AVC patients included MV orifice area z-score <-2 and transitional AVC; for non-AVC patients, predictors included MV orifice area z-score <-2, abnormal MV anatomy, and conal-septal ventricular septal defect. Independent predictors of secondary outcome for AVC patients included older age at surgery, transitional AVC, and transposition of the great arteries. CONCLUSION In children with HLV, low MV orifice area and pre-existing MV pathology are risk factors for adverse outcome after BiV repair.
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Affiliation(s)
- David Liddle
- The Heart Institute, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
| | - Addison Gearhart
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA; Department of Pediatrics, Harvard Medical School, Boston, MA, USA.
| | - Lynn A Sleeper
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA; Department of Pediatrics, Harvard Medical School, Boston, MA, USA.
| | - Minmin Lu
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA.
| | - Eric Feins
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, MA, USA; Department of Surgery, Harvard Medical School, Boston, MA, USA.
| | - David N Schidlow
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA; Department of Pediatrics, Harvard Medical School, Boston, MA, USA.
| | - Sunil Ghelani
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA; Department of Pediatrics, Harvard Medical School, Boston, MA, USA.
| | - Andrew J Powell
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA; Department of Pediatrics, Harvard Medical School, Boston, MA, USA.
| | - Sitaram Emani
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, MA, USA; Department of Surgery, Harvard Medical School, Boston, MA, USA.
| | - Rebecca S Beroukhim
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA; Department of Pediatrics, Harvard Medical School, Boston, MA, USA.
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4
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Beattie MJ, Sleeper LA, Lu M, Teele SA, Breitbart RE, Esch JJ, Salvin JW, Kapoor U, Oladunjoye O, Emani SM, Banka P. Factors associated with morbidity, mortality, and hemodynamic failure after biventricular conversion in borderline hypoplastic left hearts. J Thorac Cardiovasc Surg 2023; 166:933-942.e3. [PMID: 36803549 DOI: 10.1016/j.jtcvs.2023.01.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 01/09/2023] [Accepted: 01/17/2023] [Indexed: 01/25/2023]
Abstract
OBJECTIVE A subset of patients with borderline hypoplastic left heart may be candidates for single to biventricular conversion, but long-term morbidity and mortality persist. Prior studies have shown conflicting results regarding the association of preoperative diastolic dysfunction and outcome, and patient selection remains challenging. METHODS Patients with borderline hypoplastic left heart undergoing biventricular conversion from 2005 to 2017 were included. Cox regression identified preoperative factors associated with a composite outcome of time to mortality, heart transplant, takedown to single ventricle circulation, or hemodynamic failure (defined as left ventricular end-diastolic pressure >20 mm Hg, mean pulmonary artery pressure >35 mm Hg, or pulmonary vascular resistance >6 international Woods units). RESULTS Among 43 patients, 20 (46%) met the outcome, with a median time to outcome of 5.2 years. On univariate analysis, endocardial fibroelastosis, lower left ventricular end-diastolic volume/body surface area (when <50 mL/m2), lower left ventricular stroke volume/body surface area (when <32 mL/m2), and lower left:right ventricular stroke volume ratio (when <0.7) were associated with outcome; higher preoperative left ventricular end-diastolic pressure was not. Multivariable analysis demonstrated that endocardial fibroelastosis (hazard ratio, 5.1, 95% confidence interval, 1.5-22.7, P = .033) and left ventricular stroke volume/body surface area 28 mL/m2 or less (hazard ratio, 4.3, 95% confidence interval, 1.5-12.3, P = .006) were independently associated with a higher hazard of the outcome. Approximately all patients (86%) with endocardial fibroelastosis and left ventricular stroke volume/body surface area 28 mL/m2 or less met the outcome compared with 10% of those without endocardial fibroelastosis and with higher stroke volume/body surface area. CONCLUSIONS History of endocardial fibroelastosis and smaller left ventricular stroke volume/body surface area are independent factors associated with adverse outcomes among patients with borderline hypoplastic left heart undergoing biventricular conversion. Normal preoperative left ventricular end-diastolic pressure is insufficient to reassure against diastolic dysfunction after biventricular conversion.
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Affiliation(s)
- Meaghan J Beattie
- Department of Cardiology, Boston Children's Hospital, Boston, Mass; Department of Pediatrics, Harvard Medical School, Boston, Mass.
| | - Lynn A Sleeper
- Department of Cardiology, Boston Children's Hospital, Boston, Mass; Department of Pediatrics, Harvard Medical School, Boston, Mass
| | - Minmin Lu
- Department of Cardiology, Boston Children's Hospital, Boston, Mass
| | - Sarah A Teele
- Department of Cardiology, Boston Children's Hospital, Boston, Mass; Department of Pediatrics, Harvard Medical School, Boston, Mass
| | - Roger E Breitbart
- Department of Cardiology, Boston Children's Hospital, Boston, Mass; Department of Pediatrics, Harvard Medical School, Boston, Mass
| | - Jesse J Esch
- Department of Cardiology, Boston Children's Hospital, Boston, Mass; Department of Pediatrics, Harvard Medical School, Boston, Mass
| | - Joshua W Salvin
- Department of Cardiology, Boston Children's Hospital, Boston, Mass; Department of Pediatrics, Harvard Medical School, Boston, Mass
| | - Urvi Kapoor
- Department of Cardiology, Boston Children's Hospital, Boston, Mass
| | - Olubunmi Oladunjoye
- Department of Cardiovascular Surgery, Boston Children's Hospital, Boston, Mass
| | - Sitaram M Emani
- Department of Cardiovascular Surgery, Boston Children's Hospital, Boston, Mass; Department of Surgery, Harvard Medical School, Boston, Mass
| | - Puja Banka
- Department of Cardiology, Boston Children's Hospital, Boston, Mass; Department of Pediatrics, Harvard Medical School, Boston, Mass
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Davies SJ, DiNardo JA, Emani SM, Brown ML. A Review of Biventricular Repair for the Congenital Cardiac Anesthesiologist. Semin Cardiothorac Vasc Anesth 2023; 27:51-63. [PMID: 36470215 DOI: 10.1177/10892532221143880] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The management of children with a borderline ventricle has been debated for many years. The pursuit of a biventricular repair in these children aims to avoid the long-term sequelae of single ventricle palliation. There is a lack of anesthesia literature relating to the care of this complex heterogenous patient population. Anesthesiologists caring for these patients should have an understanding on the many different forms of physiology and the impact on provision of anesthesia and hemodynamic parameters, the goals of biventricular staging and completion as well as the pre-operative, intra-operative, and post-operative considerations relating to this high-risk group of patients.
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Affiliation(s)
- Sean J Davies
- Department of Anesthesiology, Critical Care and Pain Medicine, 1862Boston Children's Hospital, Boston, MA, USA
| | - James A DiNardo
- Department of Anesthesiology, Critical Care and Pain Medicine, 1862Boston Children's Hospital, Boston, MA, USA
| | - Sitaram M Emani
- Department of Anesthesiology, Critical Care and Pain Medicine, 1862Boston Children's Hospital, Boston, MA, USA
| | - Morgan L Brown
- Department of Anesthesiology, Critical Care and Pain Medicine, 1862Boston Children's Hospital, Boston, MA, USA
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6
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Improved Exercise Tolerance in an Adolescent Female After Failed Fontan and Subsequent Biventricular Conversion. Pediatr Cardiol 2022; 43:1669-1673. [PMID: 35678825 DOI: 10.1007/s00246-022-02931-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Accepted: 04/28/2022] [Indexed: 10/18/2022]
Abstract
We report a case of improved exercise tolerance in a single-ventricle patient following biventricular conversion. An 11 year old with a fenestrated extracardiac failing Fontan was accepted for a biventricular conversion repair at an out-of-town institution. The patient had multiple adverse cardiac events following Fontan surgery including recurrent pleural effusions, arteriovenous malformations, protein-losing enteropathy, and marked exercise intolerance. Serial cardiac catheterizations revealed chronic elevated pulmonary artery and Fontan pressures, normal left ventricular end-diastolic pressure and an adequately sized left ventricle. Cardiopulmonary exercise testing demonstrated severely reduced exercise tolerance due to ventilatory and cardiac limitations with significant arterial desaturations during exercise. Following a successful biventricular conversion, exercise tolerance improved remarkably, as evidenced by improved oxygen uptake and ventilatory efficiency. Our case demonstrates that biventricular conversion surgery may offer improvement in quality of life and exercise capacity in selected patients with failing Fontan physiology.
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7
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Scully BB, Feins EN, Tworetzky W, Ghelani S, Beroukhim R, Del Nido PJ, Emani SM. Early Experience With Reverse Double Switch Operation for the Borderline Left Heart. Semin Thorac Cardiovasc Surg 2022; 36:67-79. [PMID: 36180012 DOI: 10.1053/j.semtcvs.2022.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 09/02/2022] [Indexed: 11/11/2022]
Abstract
This study reviews our early experience with the "reverse" double switch operation (R-DSO) for borderline left hearts. A retrospective review of children with borderline left hearts who underwent R-DSO between 2017 and 2021 was conducted. Patient characteristics and early hemodynamic and clinical outcomes were collected. R-DSO was performed in 8 patients with no operative or postoperative deaths; 5 underwent decompressing bidirectional Glenn. Left ventricular (LV) poor-compliance was the dominant pathophysiology. Four patients had undergone staged LV recruitment but were not candidates for anatomical biventricular circulation due to LV hypoplasia and/or diastolic dysfunction. 7/8 patients had risk factors for Fontan circulation including pulmonary vein stenosis, pulmonary hypertension, and pulmonary artery stenosis. Median age at R-DSO was 3.7 years (19 months-12 years). All patients were in sinus rhythm at discharge. At median follow-up of 15 months (57 days-4.1 years) no mortalities, reoperations or heart transplants had occurred. All patients had normal morphologic LV systolic function. In one patient, pre-existing pulmonary hypertension (HTN) resolved after R-DSO. Reinterventions included transcatheter mitral valve replacement for residual mitral stenosis and neo-pulmonary balloon valvuloplasty. In 4 patients follow-up catheterization done at a median of 519 days (320 days-4 years) demonstrated median cardiac index of 3.2 L/min/m2 (2.2-4); median sub-pulmonary left ventricular end diastolic pressure was 9 mm Hg (7-15); median inferior vena cava/baffle pressure was 8 mm Hg (7-13). R-DSO is an alternative to anatomical biventricular repair or single ventricle palliation in patients with borderline left hearts and can result in low inferior vena cava pressures and favorable early results. This approach can also relieve pulmonary HTN and allow future transplant candidacy.
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Affiliation(s)
- Brandi Braud Scully
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts.
| | - Eric N Feins
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Wayne Tworetzky
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sunil Ghelani
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Rebecca Beroukhim
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Pedro J Del Nido
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sitaram M Emani
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
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8
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Emani SM. Management of the Borderline Left Heart and Alternatives to Fontan. World J Pediatr Congenit Heart Surg 2022; 13:645-649. [PMID: 36053112 DOI: 10.1177/21501351221116278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Management of borderline left heart can be divided into single ventricle and biventricular repair strategies. Recently, the strategy of left heart recruitment has been applied to select patients. Left heart recruitment strategies and alternatives to Fontan circulation are reviewed. The criteria utilized for decision-making include size and function of left heart structures as well as hemodynamics measured by cardiac catheterization.
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Affiliation(s)
- Sitaram M Emani
- Department of Cardiac Surgery, 1862Children's Hospital Boston, Boston, MA, USA
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9
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Akintürk H, Yörüker U, Müller M, Schranz D. Hypoplastic Left Ventricle: Left Ventricular Recruitment With Hybrid Approach. World J Pediatr Congenit Heart Surg 2022; 13:637-644. [PMID: 36053106 DOI: 10.1177/21501351221116274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Decision-making for biventricular repair (BVR) or univentricular palliation is challenging in neonates with hypoplastic left heart complex (HLHC). Hybrid strategy can be used successfully to achieve BVR in some of these patients. Between June 1998 and January 2022, 342 patients with a diagnosis of HLHS/variants, ductal-dependent lower body circulation with two ventricles, or HLHC with borderline left ventricle (LV) underwent initial bilateral pulmonary artery banding and ductal stenting in our institution. Among these 342 patients, 224 patients were defined as HLHS/variants and underwent univentricular palliation. 118 patients were determined to have borderline LV and hypoplastic left ventricular structures (HLHC, n = 48) or ductal-dependent lower body circulation with two ventricles (n = 70) considered suitable for BVR. 48 patients had multilevel obstructions including both aortic and mitral valve hypoplasia, aortic arch hypoplasia, and borderline LV. These were considered to have HLHC. These 48 HLHC patients are the subject of this report. Neonatal hybrid palliation at a median age of seven days was performed in 48 patients and 46 patients underwent BVR at a median age of 156 days. In 46 patients who underwent BVR, hospital mortality was not observed. The median follow-up was 66 months, with no late mortality. Heart transplant-free survival at 5, 10, and 15 years was 95.7%. 12 patients (26%) required reoperation and 9 (19.5%) required catheter reinterventions. Hybrid palliation may increase the chances for biventricular circulation in patients with borderline LV and small left-sided structures. Giessen hybrid approach as a left ventricular recruitment strategy achieves excellent early and long-term results.
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Affiliation(s)
- Hakan Akintürk
- Department of Pediatric Cardiac Surgery and Congenital Heart Disease, Pediatric Heart Center, Justus Liebig University, Giessen, Germany
| | - Uygar Yörüker
- Department of Pediatric Cardiac Surgery and Congenital Heart Disease, Pediatric Heart Center, Justus Liebig University, Giessen, Germany
| | - Matthias Müller
- Department of Pediatric Cardiac Anestesiology, Pediatric Heart Center, Justus Liebig University, Giessen, Germany
| | - Dietmar Schranz
- Department of Pediatric Cardiology, Goethe University, Frankfurt, Germany
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10
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Voges I, Krupickova S. Biventricular Repair or Single-Ventricle Palliation: Can Cardiovascular Magnetic Resonance Flow Imaging Help in Decision-Making? JACC. ADVANCES 2022; 1:100067. [PMID: 38938407 PMCID: PMC11198503 DOI: 10.1016/j.jacadv.2022.100067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/29/2024]
Affiliation(s)
- Inga Voges
- Department of Congenital Heart Disease and Pediatric Cardiology, University Hospital Schleswig-Holstein, Kiel, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, Kiel, Germany
| | - Sylvia Krupickova
- Department of Pediatric Cardiology, Royal Brompton Hospital, London, UK
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
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11
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Kumar SR, Detterich J. Considerations for Biventricular Conversion of Fontan Circulation. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2022; 25:11-18. [PMID: 35835511 DOI: 10.1053/j.pcsu.2022.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 04/26/2022] [Accepted: 04/29/2022] [Indexed: 11/11/2022]
Abstract
Despite significant improvements in the management of Fontan circulation in patients with single ventricle physiology, long-term outcomes continue to be suboptimal. Conversion to biventricular circulation is increasingly gaining popularity, particularly in the subset of patients who are not ideal Fontan candidates. Meticulous image-guided planning, extensive preoperative discussions, and a team-based approach are required for successful execution of complex biventricular conversion. A segmental approach to the anatomy of the heart defect allows methodical planning of the technique of biventricular conversion. Ventricular size and function continue to be the Achilles heel of successful biventricular repair. Long-term studies comparing outcomes in patients converted to biventricular circulation to those in patients with Fontan physiology are required to appropriately tailor management approaches to an individual patient.
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Affiliation(s)
- S Ram Kumar
- Division of Cardiothoracic Surgery, Department of Surgery, University of Southern California, Los Angeles, California; Department of Pediatrics, University of Southern California, Los Angeles, California; Heart Institute, Children's Hospital of Los Angeles, Los Angeles, California.
| | - Jon Detterich
- Division of Cardiology, University of Southern California, Los Angeles, California; Department of Pediatrics, University of Southern California, Los Angeles, California; Heart Institute, Children's Hospital of Los Angeles, Los Angeles, California
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12
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Rodríguez MR, DiNardo JA. Biventricular Repair as an Alternative to Single Ventricle Palliation in the Child with Hypoplastic Left Heart Structures: What the Anesthesiologist Should Know. J Cardiothorac Vasc Anesth 2022; 36:3927-3938. [DOI: 10.1053/j.jvca.2022.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 06/04/2022] [Accepted: 06/13/2022] [Indexed: 11/11/2022]
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13
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Greenleaf CE, Salazar JD. Biventricular Conversion for Hypoplastic Left Heart Variants: An Update. CHILDREN 2022; 9:children9050690. [PMID: 35626869 PMCID: PMC9139433 DOI: 10.3390/children9050690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 04/29/2022] [Accepted: 05/02/2022] [Indexed: 11/16/2022]
Abstract
Ongoing concerns with single-ventricle palliation morbidity and poor outcomes from primary biventricular strategies for neonates with borderline left heart structures have led some centers to attempt alternative strategies to obviate the need for ultimate Fontan palliation and limit the risk to the child during the vulnerable neonatal period. In certain patients who are traditionally palliated toward single-ventricle circulation, biventricular circulation is possible. This review aims to delineate the current knowledge regarding converting certain patients with borderline left heart structures from single-ventricle palliation toward biventricular circulation.
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14
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Shi B, Pan Y, Luo W, Luo K, Sun Q, Liu J, Zhu Z, Wang H, He X, Zheng J. Impact of 3D Printing on Short-Term Outcomes of Biventricular Conversion From Single Ventricular Palliation for the Complex Congenital Heart Defects. Front Cardiovasc Med 2021; 8:801444. [PMID: 34993241 PMCID: PMC8724052 DOI: 10.3389/fcvm.2021.801444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 11/23/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Although Fontan palliation seems to be inevitable for many patients with complex congenital heart defects (CHDs), candidates with appropriate conditions could be selected for biventricular conversion. We aimed to summarize our single-center experience in patient selection, surgical strategies, and early outcomes in biventricular conversion for the complex CHD.Methods: From April 2017 to June 2021, we reviewed 23 cases with complex CHD who underwent biventricular conversion. Patients were divided into two groups according to the development of the ventricles: balanced ventricular group (15 cases) and imbalanced ventricular group (8 cases). Early and short-term outcomes during the 30.2 months (range, 4.2–49.8 months) follow-up period were compared.Results: The overall mortality rate was 4.3% with one death case. In the balanced ventricular group, 6 cases received 3D printing for pre-operational evaluation. One case died because of heart failure in the early postoperative period. One case received reoperation due to the obstruction of the superior vena cava. In the imbalanced ventricular group, the mean left ventricular end-diastolic volume was (33.6 ± 2.1) ml/m2, the mean left ventricular end-diastolic pressure was 9.1 ± 1.9 mmHg, and 4 cases received 3D printing. No death occurred while one case implanted a pacemaker due to a third-degree atrioventricular block. The pre-operational evaluation and surgery simulation with a 3D printing model helped to reduce bypass time in the balanced group (p < 0.05), and reduced both bypass and aorta clamp time in the imbalanced group (p < 0.05). All patients presented great cardiac function in the follow-up period.Conclusion: Comprehensive evaluation, especially 3D printing technique, was conducive to finding the appropriate cases for biventricular conversion and significantly reduced surgery time. Biventricular conversion in selected patients led to promising clinical outcomes, albeit unverified long-term results.
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Affiliation(s)
- Bozhong Shi
- Department of Cardiothoracic Surgery, Shanghai Children's Medical Center Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yanjun Pan
- Department of Cardiothoracic Surgery, Shanghai Children's Medical Center Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Weiru Luo
- Department of Cardiothoracic Surgery, Shanghai Children's Medical Center Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Kai Luo
- Department of Cardiothoracic Surgery, Shanghai Children's Medical Center Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Qi Sun
- Department of Cardiothoracic Surgery, Shanghai Children's Medical Center Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jinlong Liu
- Department of Cardiothoracic Surgery, Shanghai Children's Medical Center Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai Children's Medical Center, Institute of Pediatric Translational Medicine, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Zhongqun Zhu
- Department of Cardiothoracic Surgery, Shanghai Children's Medical Center Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Hao Wang
- Department of Cardiothoracic Surgery, Shanghai Children's Medical Center Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Hao Wang
| | - Xiaomin He
- Department of Cardiothoracic Surgery, Shanghai Children's Medical Center Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
- *Correspondence: Xiaomin He
| | - Jinghao Zheng
- Department of Cardiothoracic Surgery, Shanghai Children's Medical Center Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Jinghao Zheng
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15
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Oh NA, Hong X, Doulamis IP, Meibalan E, Peiseler T, Melero-Martin J, García-Cardeña G, Del Nido PJ, Friehs I. Abnormal Flow Conditions Promote Endocardial Fibroelastosis Via Endothelial-to-Mesenchymal Transition, Which Is Responsive to Losartan Treatment. JACC Basic Transl Sci 2021; 6:984-999. [PMID: 35024504 PMCID: PMC8733675 DOI: 10.1016/j.jacbts.2021.10.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 10/05/2021] [Accepted: 10/05/2021] [Indexed: 12/14/2022]
Abstract
EFE is a congenital cardiac pathology contributing to increased morbidity and mortality. The pathologic triggers of EFE remain to be characterized. To determine whether abnormal flow promotes EFE development, we used in vivo neonatal rodent surgical models and an in vitro model using human primary endocardial cells We established novel surgical model with flow profiles seen in patients that develop EFE. Static and turbulent flow conditions promoted EFE development in neonatal rodent hearts. Losartan treatment is shown to significantly ameliorate EFE progression and decreases mRNA and protein expression of EndoMT markers in neonatal rodent hearts. RNAseq analysis of human endocardial cells subjected to different flow conditions show that normal flow suppresses gene expression critical for mesenchymal differentiation and Notch signaling.
Endocardial fibroelastosis (EFE) is defined by fibrotic tissue on the endocardium and forms partly through aberrant endothelial-to-mesenchymal transition. However, the pathologic triggers are still unknown. In this study, we showed that abnormal flow induces EFE partly through endothelial-to-mesenchymal transition in a rodent model, and that losartan can abrogate EFE development. Furthermore, we translated our findings to human endocardial endothelial cells, and showed that laminar flow promotes the suppression of genes associated with mesenchymal differentiation. These findings emphasize the role of flow in promoting EFE in endocardial endothelial cells and provide a novel potential therapy to treat this highly morbid condition.
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Key Words
- AR, aortic regurgitation
- EFE, endocardial fibroelastosis
- EndoMT, endothelial-to-mesenchymal transition
- GO, gene ontology
- HLHS, hypoplastic left heart syndrome
- HUEEC, human endocardial endothelial cells
- HUVEC, human umbilical vein endothelial cells
- LSS, laminar shear stress
- LV, left ventricle
- congenital heart disease
- endocardial endothelial cells
- endocardial fibroelastosis
- endothelial-to-mesenchymal transition
- wall shear stress
- α-SMA, alpha-smooth muscle actin
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Affiliation(s)
- Nicholas A Oh
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Cardiothoracic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Xuechong Hong
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Ilias P Doulamis
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Elamaran Meibalan
- Laboratory for Systems Mechanobiology, Center for Excellence in Vascular Biology, Department of Pathology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Teresa Peiseler
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Juan Melero-Martin
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Guillermo García-Cardeña
- Laboratory for Systems Mechanobiology, Center for Excellence in Vascular Biology, Department of Pathology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Pedro J Del Nido
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Ingeborg Friehs
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
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16
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Corno AF, Adebo DA, LaPar DJ, Salazar JD. Modern advances regarding interatrial communication in congenital heart defects. J Card Surg 2021; 37:350-360. [PMID: 34842296 DOI: 10.1111/jocs.16166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 11/12/2021] [Accepted: 11/19/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND The interatrial communication, one of the most frequent congenital heart defects, represents an important intracardiac shunt between systemic and pulmonary circulations. Direction and magnitude of the interatrial shunting depends upon several features, including defect size, shape and location, pressure difference between right and left atrium, and difference in right and left ventricular compliance. METHODS In this review article, the presence or absence of interatrial communication, and its role, have been analyzed, as they can have a critical impact on the cardiovascular physiopathology, and the interatrial communication can prove to be either clinically harmful, useful or indispensable. Accordingly, the utility and role of the interatrial communication in modern congenital, pediatric and adult, disease has evolved, with modification of the indications to close, maintain patency, or create an interatrial communication. RESULTS The interatrial communication and shunting can be manipulated to maximize the oxygen delivery to the tissues, accordingly with the underlying congenital heart defect. While not always relevant to patients with bi-ventricular circulations, this becomes extremely important in children and adults with complex congenital heart defects. CONCLUSIONS With improving long-term survival for the vast majority of congenital heart patients, an advanced understanding of the role and utility of the interatrial communication, and of all the possibilities of its manipulation, is essential to improve the patient outcomes.
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Affiliation(s)
- Antonio F Corno
- Department of Pediatric and Congenital Heart Surgery, Houston Children's Heart Institute, Memorial Hermann Children's Hospital, University of Texas Health, McGovern Medical School, Houston, Texas, USA
| | - Dilachew A Adebo
- Department of Pediatric and Congenital Cardiology, Houston Children's Heart Institute, Memorial Hermann Children's Hospital, University of Texas Health, McGovern Medical School, Houston, Texas, USA
| | - Damien J LaPar
- Department of Pediatric and Congenital Heart Surgery, Houston Children's Heart Institute, Memorial Hermann Children's Hospital, University of Texas Health, McGovern Medical School, Houston, Texas, USA
| | - Jorge D Salazar
- Department of Pediatric and Congenital Heart Surgery, Houston Children's Heart Institute, Memorial Hermann Children's Hospital, University of Texas Health, McGovern Medical School, Houston, Texas, USA
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17
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Kwak JG, Del Nido PJ, Piekarski B, Marx G, Emani SM. Restriction of Atrial Septal Defect Leads to Growth of Hypoplastic Ventricle in Patients with Borderline Right or Left Heart. Semin Thorac Cardiovasc Surg 2021; 34:215-223. [PMID: 34000428 DOI: 10.1053/j.semtcvs.2021.03.039] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 03/04/2021] [Indexed: 12/11/2022]
Abstract
Patients with borderline hypoplastic right or left ventricle and VSD may be candidates for either single ventricle palliation or staged ventricular recruitment (SVR) followed by eventual biventricular conversion. Components of SVR include restriction of atrial septal defects (ASD) without ventricular septal defects (VSD) closure and addition of accessory pulmonary blood flow. This study evaluated the impact of ASD restriction on ventricular growth and function. We retrospectively reviewed patients with borderline ventricular hypoplasia and VSD who underwent a staged ventricular recruitment (SVR) procedure from 2012 to June 2019. Pre- and post-recruitment MRI and echocardiogram data were compared and analyzed. We excluded cases in which we intentionally restricted VSD with simultaneous ASD restriction. Forty-six patients (41 with right-dominant ventricle, 25 with risk factors for Fontan procedure) underwent SVR at a median age of 15.1 months' (interquartile range (IQR), 7.2-37.2 months'). The median indexed ventricular end-diastolic volume, end-systolic volume, and stroke volume according to cardiac MRI significantly increased at median 11.0 months' (IQR:7.8~14.1 months') after recruitment. Among them, except 2 operative mortalities after SVR, 26 patients underwent bi-ventricular repair (56.5% including one and a half ventricle repair) at a median of 8.0 months' (IQR: 6.2-12.2 months') after recruitment. Fifteen patients await biventricular completion, and 3 patients underwent single ventricle palliation. Pulmonary blood flow (Qp) tended to increase after recruitment regardless of type of pulmonary blood flow modification without statistical significance. Six patients died at a median duration of 6.5 months' (IQR: 2.9-11.7) after SVR; 3 patients died after biventricular completion, 2 after recruitment, and 1 after returning to single ventricle palliation. All of them were considered poor Fontan candidates due to severe atrioventricular valve regurgitation, pulmonary hypertension, pulmonary vein stenosis, or airway stenosis. Restriction of the atrial septum leads to the growth of hypoplastic ventricle in patients with ventricular septal defects who undergo SVR regardless of the preoperative characteristics, and eventual biventricular repair can be performed in a subgroup of these patients. Future work is necessary to optimize timing of SVR and method of accessory pulmonary blood flow.
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Affiliation(s)
- Jae Gun Kwak
- Department of Cardiovascular Surgery, College of Medicine, Seoul National University, Boston Children's Hospital, Boston, Massachusetts; Department of Thoracic and Cardiovascular Surgery, Seoul National University Children's Hospital, College of Medicine, Seoul National University, Seoul, Republic of Korea.
| | - Pedro J Del Nido
- Department of Cardiovascular Surgery, College of Medicine, Seoul National University, Boston Children's Hospital, Boston, Massachusetts
| | - Breanna Piekarski
- Department of Cardiovascular Surgery, College of Medicine, Seoul National University, Boston Children's Hospital, Boston, Massachusetts
| | - Gerald Marx
- Department of Pediatric Cardiology, Boston Children's Hospital, Boston, Massachusetts
| | - Sitaram M Emani
- Department of Cardiovascular Surgery, College of Medicine, Seoul National University, Boston Children's Hospital, Boston, Massachusetts.
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18
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Biventricular conversion after Fontan completion: A preliminary experience. J Thorac Cardiovasc Surg 2021; 163:1211-1223. [PMID: 34045059 DOI: 10.1016/j.jtcvs.2021.04.076] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 03/23/2021] [Accepted: 04/17/2021] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To assess the feasibility and outcomes of biventricular conversion following takedown of Fontan circulation. METHODS Retrospective analysis of patients who had takedown of Fontan circulation and conversion to biventricular circulation at a single center from September 2007 to April 2020. Failing Fontan physiology was defined as Fontan circulation pressure >15 mm Hg and/or the presence of associated complications. RESULTS Biventricular conversion was performed in 23 patients at a median age of 10.0 (7.5-13.0) years. Indications included failing Fontan physiology in 15 (65%) and elective takedown in 8 (35%) patients. A subset of patients (n = 6) underwent procedures for staged recruitment of the nondominant ventricle before conversion. Median z score of end-diastolic volume of borderline ventricle before takedown was -2.3 (-3.3, -1.3). Hypoplastic left heart syndrome (P < .01) and sub-/aortic stenosis (P < .01) were more common in these patients. Biventricular conversion with or without staged ventricular recruitment led to a significant increase in indexed end-diastolic volume (P < .01), indexed end-systolic volume (P < .01), and ventricular mass (P < .01) of the nondominant ventricle (14 right, 9 left ventricle). There were 5 (22%) deaths (1 [4%] early death). All who underwent elective biventricular conversion survived, whereas 2-year survival rate for patients with a failing Fontan circulation was 72.7% (95% confidence interval, 37%-90%). The overall, 3-year reoperation-free survival was 86.7% (95% confidence interval, 56%-96%). Left dominant atrioventricular canal defect (P < .01) and early era of biventricular conversion (P = .02) were significant predictors for mortality. CONCLUSIONS A primary as well as a staged biventricular conversion is feasible in patients who have had previous Fontan procedure. Although this provides an alternative to transplantation in patients with failing Fontan, outcomes are worse in those with failing Fontan compared with elective takedown of Fontan circulation. Optimal timing needs further evaluation.
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19
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Greenleaf C, Sinha R, Cerra Z, Chen P, Adebo D, Salazar JD. Development of a biventricular conversion program: A new paradigm. J Card Surg 2021; 36:2013-2020. [PMID: 33783014 DOI: 10.1111/jocs.15487] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 02/23/2021] [Accepted: 02/25/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND Borderline small ventricular size or technical issues precluding the use of both ventricles may lead to single ventricle palliation. Fontan complications have led some centers to look for alternatives to the traditional pathway. The objective of this study is to evaluate the essential philosophy and outcomes of a new biventricular (BiV) conversion program. METHODS The prospectively collected Children's Memorial Hermann Heart Institute Society of Thoracic Surgeon's Database was retrospectively reviewed between July 2017 and July 2020. RESULTS Thirteen patients met inclusion criteria and underwent BiV conversion during that time. The most frequent diagnosis was malposed great arteries and a ventricular septal defect (VSD) in 4 (31%) patients. Seven (54%) patients were in the first interstage, and 1 (8%) patient had already undergone a Fontan operation before their BiV conversion operation. One or more risk factors for single ventricle palliation (genetic syndrome ≥ moderate atrioventricular valve regurgitation ≥ moderate ventricular dysfunction, presence of signs of Fontan failure) were present in 3 (23%) patients. The median left ventricular end diastolic pressure increased from 5.5 mmHg (4-10 mmHg) to 10 mmHg (6-20 mmHg) postoperatively (p < .05). The right ventricular pressure (RVP) was estimated as less than half systemic in all six patients who were able to be estimated. At a median follow-up of 22.6 months (0.3-36.4 months), 12 (92%) patients are alive. CONCLUSIONS BiV conversion is feasible with reasonable short-term clinical outcomes. Mortality risk is low, but as seen in other studies, the risk of reintervention is high.
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Affiliation(s)
- Christopher Greenleaf
- Children's Heart Institute, Memorial Hermann Hospital, University of Texas Health McGovern Medical School, Houston, Texas, USA
| | - Raina Sinha
- Pediatric and Adult Congenital Cardiac Surgery, Connecticut Children's Medical Center, University of Connecticut, Hartford, Connecticut, USA
| | - Zachary Cerra
- Children's Heart Institute, Memorial Hermann Hospital, University of Texas Health McGovern Medical School, Houston, Texas, USA
| | - Peter Chen
- Children's Heart Institute, Memorial Hermann Hospital, University of Texas Health McGovern Medical School, Houston, Texas, USA
| | - Dilachew Adebo
- Children's Heart Institute, Memorial Hermann Hospital, University of Texas Health McGovern Medical School, Houston, Texas, USA
| | - Jorge D Salazar
- Children's Heart Institute, Memorial Hermann Hospital, University of Texas Health McGovern Medical School, Houston, Texas, USA
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20
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Sojak V, Bokenkamp R, Kuipers I, Schneider A, Hazekamp M. Left heart growth and biventricular repair after hybrid palliation. Interact Cardiovasc Thorac Surg 2021; 32:792-799. [PMID: 33547474 DOI: 10.1093/icvts/ivab004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 11/28/2020] [Accepted: 12/12/2020] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES We evaluated the outcomes of biventricular repair after initial hybrid palliation performed in small infants with various forms of left ventricle hypoplasia. METHODS Between September 2010 and January 2020, a total of 27 patients had biventricular repair after hybrid palliation at a median age of 11 days. Indications for the hybrid approach included growth promotion of the left ventricle outflow tract and/or the aortic valve in 14 patients and that of the left ventricle in 13 patients. Seven reinterventions and 7 reoperations were performed during the interstage period. Significant growth of left ventricle parameters was noted during the median interstage period of 62 days. Sixteen subjects had aortic arch repair, ventricular septal defect closure and relief of subaortic stenosis; 5 patients had the Ross-Konno procedure; 5 patients underwent the Yasui procedure; and 1 patient had unbalanced atrioventricular septal defect and aortic arch repair. RESULTS Twenty-three patients (85.2%) are alive at a median follow-up of 3.3 years. Two and 3 patients died early and late after achieving biventricular circulation, respectively. There were 22 reinterventions and 15 reoperations after biventricular repair. CONCLUSIONS Hybrid palliation can stimulate left heart growth in some patients with left ventricle hypoplasia. More patients may eventually achieve biventricular circulation than was initially thought. Additional interventions and operations are foreseeable. Despite ventricular rehabilitation, some patients with borderline left ventricles may develop restrictive physiology.
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Affiliation(s)
- Vladimir Sojak
- Department of Thoracic Surgery, Leiden University Medical Center, Leiden, Netherlands
| | - Regina Bokenkamp
- Department of Pediatric Cardiology, Leiden University Medical Center, Leiden, Netherlands
| | - Irene Kuipers
- Department of Pediatric Cardiology, Amsterdam University Medical Center, Amsterdam, Netherlands
| | - Adriaan Schneider
- Department of Thoracic Surgery, Leiden University Medical Center, Leiden, Netherlands
| | - Mark Hazekamp
- Department of Thoracic Surgery, Leiden University Medical Center, Leiden, Netherlands
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21
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Desai M. Small and borderline left ventricular outflow tract - a perplexing maladie. Indian J Thorac Cardiovasc Surg 2021; 37:123-130. [PMID: 33584029 PMCID: PMC7858724 DOI: 10.1007/s12055-020-01122-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 11/27/2020] [Accepted: 12/08/2020] [Indexed: 10/22/2022] Open
Abstract
The left ventricular outflow tract (LVOT) comprises of the subvalvular area, the aortic valve, and the supravalvular region. Obstructive lesion of LVOT is a spectrum with varying levels and degree of obstruction with or without associated hypoplasia of the left ventricle. Decision-making in small and borderline LVOT can be challenging. Imaging modalities such as echocardiography and magnetic resonance imaging and scores based on imaging aid in the decision making in truly borderline cases. Newer treatment strategies like staged left ventricular rehabilitation and hybrid procedure have come to the fore in the past decade or so. Although these do not address small LVOT per se, they delay the decision-making to a more appropriate age. The goal of management in these cases is to achieve a biventricular repair whenever feasible. Several surgical techniques could be employed to achieve this goal. However, it is important to be cognizant of the fact that an overzealous approach to achieve a biventricular repair might be counterproductive. A univentricular palliation could be a safer alternative; especially considering the possibility of a future transplant candidacy.
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Affiliation(s)
- Manan Desai
- Pediatric Cardiothoracic Surgery, Lucile Packard Children’s Hospital, Stanford University, CA 94304 Palo Alto, USA
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22
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Koubský K, Tláskal T, Chaloupecký V, Janoušek J. How many types of circulation can a boy have during his life? A case of aortic stenosis with a borderline left ventricle. ESC Heart Fail 2020; 8:774-777. [PMID: 33295691 PMCID: PMC7835500 DOI: 10.1002/ehf2.13134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 10/26/2020] [Accepted: 11/13/2020] [Indexed: 11/14/2022] Open
Abstract
Severe aortic stenosis can be accompanied by various degrees of left ventricular underdevelopment. The assessment whether a borderline‐sized left ventricle can or cannot support the systemic circulation is crucial. The decision‐making still remains challenging. We present a case that illustrates that the development of haemodynamic parameters can be difficult to estimate, even in the long term. The patient went from biventricular to univentricular circulation and back and could finally be palliated by heart transplantation. Modern technology including long‐term mechanical cardiac support as a bridge to candidacy and drug therapy for pulmonary hypertension were vital to successfully combat a previously lethal disease.
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Affiliation(s)
- Karel Koubský
- Children's Heart Centre, 2nd Faculty of Medicine, Charles University in Prague and Motol University Hospital, V Uvalu 84, Prague, 15006, Czech Republic
| | - Tomáš Tláskal
- Children's Heart Centre, 2nd Faculty of Medicine, Charles University in Prague and Motol University Hospital, V Uvalu 84, Prague, 15006, Czech Republic
| | - Václav Chaloupecký
- Children's Heart Centre, 2nd Faculty of Medicine, Charles University in Prague and Motol University Hospital, V Uvalu 84, Prague, 15006, Czech Republic
| | - Jan Janoušek
- Children's Heart Centre, 2nd Faculty of Medicine, Charles University in Prague and Motol University Hospital, V Uvalu 84, Prague, 15006, Czech Republic
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23
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Abstract
PURPOSE OF REVIEW The development of biventricular repair and conversion pathways for patients with borderline hypoplastic heart disease represents an area of recent inquiry and innovation. This review summarizes emerging techniques and novel treatment algorithms for borderline hypoplastic heart disease with a focus on surgical advances within the last 10 years. RECENT FINDINGS Many patients with borderline hypoplastic heart disease are amenable to primary biventricular repair, or biventricular conversion following single-ventricle palliation coupled with ventricular rehabilitation strategies. New insights into the potential for growth and recovery of borderline ventricles have been uncovered. However, questions remain regarding optimal patient selection and the long-term outcomes of select patient groups treated with single-ventricle palliation versus biventricular repair/conversion or transplantation. Efforts to direct a greater proportion of borderline hypoplastic heart patients towards a biventricular circulation are accelerating and represent important avenues for progress and future research in the field of congenital heart disease.
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24
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Conversion of prior univentricular repairs to septated circulation: Case selection, challenges, and outcomes. Indian J Thorac Cardiovasc Surg 2020; 37:91-103. [PMID: 33603287 DOI: 10.1007/s12055-020-00938-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Revised: 02/05/2020] [Accepted: 02/07/2020] [Indexed: 10/23/2022] Open
Abstract
Objectives Complex congenital heart defects that present earlier in life are sometimes channelled in the single ventricle pathway, because of anatomical or logistic challenges involved in biventricular correction. Given the long-term functional and survival advantage, and with the surgeons' improved understanding of the cardiac anatomy, we have consciously explored the feasibility of a biventricular repair in these patients when they presented later for Fontan completion. We present a single institution's 10-year experience in achieving biventricular septation of prior univentricular repairs, the technical and physiological challenges and the surgical outcomes. Methods Between June 2010 and December 2019, 246 patients were channelized in the single ventricle pathway, of which 32 patients were identified as potential biventricular candidates at the time of evaluation for Fontan palliation, considering their anatomic feasibility. The surgical technique involves routing of the left ventricle to the aorta across the ventricular septal defect, ensuring an adequate sized right ventricular cavity, establishing right ventricle-pulmonary artery continuity and taking down the Glenn shunt with rerouting of the superior vena cava to the right atrium. This is a retrospective study where we reviewed the unique physiological and surgical characteristics of this subset of patients and analysed their surgical outcomes and complications. Results Biventricular conversion was achieved in all cases except in 3 patients, who had the Glenn shunt retained leading to a one and a half ventricle repair. The average age of the patients was 4.9 years of whom 18 were male. The average cardiopulmonary bypass time was 371 min with an average cross clamp time of 162 min. There was one mortality in a patient with corrected transposition of great arteries (c-TGA) with extensive arterio-venous malformations (AVMs). At a median follow-up of 60 months, all patients remained symptom free except two with NYHA II symptoms, one being treated for branch pulmonary artery stenosis with balloon dilatation and the other with multiple AVMs who needed coil closure. One patient with branch pulmonary artery (PA) stenosis required balloon dilatation and stent placement. Conclusion The possibility of achieving the surgical goal in this unique subset of patients evolves with the progressive experience of the congenital heart surgeon. Case selection is a crucial aspect in achieving the desired outcome, and this 'borderline' substrate is often recognized at the time of evaluation for the Fontan completion. A comprehensive preoperative imaging and planning helps in achieving the surgical septation and reconnection to achieve the desired physiological circulation. Though technically challenging, the surgery has excellent short- and mid-term outcomes as evidenced by our 10-year experience.
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25
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From Fontan to Anatomical Repair 16 Years Later. Ann Thorac Surg 2020; 111:e15-e17. [PMID: 32540435 DOI: 10.1016/j.athoracsur.2020.04.110] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 04/10/2020] [Accepted: 04/18/2020] [Indexed: 11/23/2022]
Abstract
Decision making for univentricular or anatomical repair remains challenging in children with borderline left ventricle. Unpredictable outcomes have led many caregivers to pursue a single-ventricle strategy. We describe 2 cases of patients with borderline left ventricle initially palliated with univentricular strategy followed by very late conversion to anatomical repair 4 and 16 years later. Anatomical conversion should be considered for these patients even many years later. During the first palliation stages, hemodynamic conditions preserving the potential for growth of the left ventricle should be maintained.
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26
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Alsoufi B. Commentary: Diastolic dysfunction following biventricular conversion: When physiology beats anatomy. J Thorac Cardiovasc Surg 2019; 159:647-648. [PMID: 31668541 DOI: 10.1016/j.jtcvs.2019.09.104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 09/17/2019] [Accepted: 09/17/2019] [Indexed: 10/25/2022]
Affiliation(s)
- Bahaaldin Alsoufi
- Department of Cardiovascular and Thoracic Surgery, University of Louisville School of Medicine, Louisville, Ky.
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27
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Weixler V, Hammer PE, Marx GR, Emani SM, del Nido PJ, Friehs I. Flow disturbances and progression of endocardial fibroelastosis — a case report. Cardiovasc Pathol 2019; 42:1-3. [DOI: 10.1016/j.carpath.2019.04.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 04/26/2019] [Accepted: 04/30/2019] [Indexed: 11/15/2022] Open
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28
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d'Udekem Y, Tweddell JS, Karl TR. The great debate series: surgical treatment of aortic valve abnormalities in children. Eur J Cardiothorac Surg 2019; 53:919-931. [PMID: 29668975 DOI: 10.1093/ejcts/ezy069] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Accepted: 01/22/2018] [Indexed: 11/13/2022] Open
Abstract
This article is the latest in an EJCTS series entitled 'The Great Debates'. We have chosen the topic of aortic valve (AoV) surgery in children, with a focus on infants and neonates. The topic was selected due to the significant challenges that AoV problems in the young may present to the surgical team. There are many areas of active controversy, despite the vast accumulated world experience. We have tried to incorporate many of these issues in the questions posed, not claiming to be all-inclusive. The individuals invited to this debate are experts in paediatric valve surgery, with broad and successful clinical experiences on multiple continents. We hope that the facts and opinions presented in this debate will generate interest and discussion and perhaps prove useful in decision-making for future complex valve cases.
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Affiliation(s)
- Yves d'Udekem
- Cardiac Surgical Unit, Royal Children's Hospital, Melbourne, VIC, Australia
| | - James S Tweddell
- Department of Cardiothoracic Surgery, Cincinnati Children's Hospital, Cincinnati, OH, USA
| | - Tom R Karl
- Johns Hopkins All Children's Heart Institute, St. Petersburg, FL, USA.,European Journal of Cardio-Thoracic Surgery
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29
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Assessing the borderline ventricle in a term infant: combining imaging and physiology to establish the right course. Curr Opin Cardiol 2018; 33:95-100. [PMID: 29084001 DOI: 10.1097/hco.0000000000000466] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
PURPOSE OF REVIEW The purpose of this review is to describe the challenges associated with the diagnosis and treatment of children with borderline ventricles. A borderline ventricle is one in which there is concern that it will not be able to support its circulation. If a biventricular repair is attempted and fails, outcome is often poor. Thus, this early decision is important. RECENT FINDINGS For the borderline right ventricle, options to add an additional source of pulmonary blood flow make the surgical strategy a bit more flexible than for patients with a borderline left ventricle. In general, outcome for a so-called one and one-half ventricle repair are generally good, though the long-term outcome and the effects of this physiology on lifelong exercise performance and quality of life remain to be seen. For the small left ventricle, often multiple surgeries are required to 'force' blood into the left ventricle and potentially help it grow. Though this strategy is successful in some, in others it results in significant residual cardiac issues including pulmonary hypertension. SUMMARY Determining whether a patient will be better off in the long term with a marginal biventricular repair versus a Fontan circulation remains one of the most difficult problems in the field of pediatric cardiology and cardiac surgery.
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Nathan M, Emani S, Del Nido PJ. Reply to Buratto et al. Eur J Cardiothorac Surg 2018; 53:1296. [PMID: 29365088 DOI: 10.1093/ejcts/ezx500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Accepted: 12/18/2017] [Indexed: 11/13/2022] Open
Affiliation(s)
- Meena Nathan
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, MA, USA.,Department of Surgery, Harvard Medical School, Boston, MA, USA
| | - Sitaram Emani
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, MA, USA.,Department of Surgery, Harvard Medical School, Boston, MA, USA
| | - Pedro J Del Nido
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, MA, USA.,Department of Surgery, Harvard Medical School, Boston, MA, USA
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Delius RE. 2-V or not 2-V: That is the question…plus some musings on thinking out of the box. J Thorac Cardiovasc Surg 2017; 154:583-584. [DOI: 10.1016/j.jtcvs.2017.03.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Accepted: 03/02/2017] [Indexed: 12/19/2022]
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Bacha E. Borderline left ventricle: Trying to see the forest for the trees. J Thorac Cardiovasc Surg 2017; 154:570-571. [PMID: 28434618 DOI: 10.1016/j.jtcvs.2017.03.093] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Accepted: 03/21/2017] [Indexed: 10/19/2022]
Affiliation(s)
- Emile Bacha
- Section of Congenital and Pediatric Cardiac Surgery, Division of Cardiac, Thoracic and Vascular Surgery, Morgan Stanley Children's Hospital, NewYork-Presbyterian, Columbia University, New York, NY.
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