Partial biventricular repair for complex congenital heart defects: an intermediate option for complicated anatomy or functionally borderline right complex heart

Effectiveness of Bidirectional Glenn Shunt Placement for Palliation in Complex Congenitally Corrected Transposed Great Arteries

Surgery for complex congenitally corrected transposed great arteries is one of the greatest challenges in cardiovascular surgery. We report our experience with bidirectional Glenn shunt placement as a palliative procedure for complex congenitally corrected transposition. We retrospectively identified 50 consecutive patients who had been diagnosed with congenitally corrected transposition accompanied by left ventricular outflow tract obstruction and ventricular septal defect and who had then undergone palliative bidirectional Glenn shunt placement at our institution from January 2005 through December 2014. Patients were divided into 3 groups according to subsequent surgeries: Fontan completion (total cavopulmonary connection, 13 patients) (group 1), anatomic repair (hemi-Mustard and Rastelli procedures without Glenn takedown, 11 patients) (group 2), and prolonged palliation (no further surgery, 26 patients) (group 3). After shunt placement, no patient died or had ventricular dysfunction. Overall, mean oxygen saturation increased significantly from 79.5% ± 13.5% preoperatively to 94.1% ± 7.3% (P <0.001). The median time from shunt placement to Fontan completion and anatomic repair, respectively, was 2.1 years (range, 1.6-5.2 yr) and 1.1 years (range, 0.6-2.4 yr). Only 2 late deaths occurred, both in group 1. In group 3, time from shunt placement to latest follow-up was 4.5 years (range, 2.3-8 yr). At latest follow-up, mean oxygen saturation was 91.6% ± 10.3%, and no patients had impaired ventricular function. Bidirectional Glenn shunt placement as an optional palliative procedure for complex congenitally corrected transposition has favorable outcomes. Later, patients can feasibly be treated by Fontan completion or anatomic repair. Use of a bidirectional Glenn shunt for open-ended palliation is also acceptable.

One and half ventricle repair: rationale, indications, and results

Surgical strategies in patients with functionally or anatomically borderline right ventricles include a high-risk biventricular repair, a Fontan procedure, or a one and half ventricle repair (also referred to as the partial biventricular repair). One and half ventricle repair (1.5VR) circumvents the high early mortality of a biventricular repair and also the late morbidity of the Fontan. The two most common indications for a 1.5VR are a small pulmonary ventricle and a dilated poorly functioning pulmonary ventricle. Extension of 1.5VR to patients undergoing anatomical repair for congenitally corrected transposition of great arteries, straddling tricuspid valves, and severe Ebstein's anomaly has facilitated biventricular repair with decreased mortality. We reviewed the relevant literature on this subject in detail and describe its rationale, indications and its early and late results.

Anatomical Repair Conversion After Bidirectional Cavopulmonary Shunt for Complex Cardiac Anomalies: Palliation is Not a One-Way Path

Complex cardiac anomalies are sometimes channeled toward Fontan palliation for various reasons. Nevertheless, anatomical repair after bidirectional cavopulmonary shunt may be another option with theoretical benefits. In this study, we report our experience with anatomical repair conversion in challenging patients who had been palliated with bidirectional cavopulmonary shunt. Retrospective review was conducted in patients who underwent anatomical repair conversion from prior bidirectional cavopulmonary shunt palliation between January 2008 and March 2016. Patients who underwent a planned staged 1½-ventricular repair were excluded. Twenty-three patients underwent anatomical repair conversion at a median age of 6.5 years (range 2.7-20.0 years). The interval time between palliation and conversion was 4.6 ± 2.4 years (range 0.9-12.4). Indications for conversion were high-risk Fontan candidates (n = 11) and preference for biventricular anatomy (n = 12). In eight of the patients, bidirectional cavopulmonary shunts were taken down and superior vena cava was reconnected to the right atrium with Gore-Tex tube or bovine jugular venous tube. Mean cardiopulmonary bypass and aortic cross-clamp times were 225.6 ± 107.0 and 138.3 ± 76.6 min, respectively. After a mean follow-up of 2.7 ± 2.2 years, there was no mortality and reoperation. No patients presented sinoatrial node dysfunction and superior venous cave stenosis. All the patients were in the New York Heart Association functional class I or II. Patients with previous bidirectional cavopulmonary shunt should be re-evaluated before completion of Fontan and, if cardiac anatomy allows, anatomical repair conversion may be considered, especially in patients with high-risk Fontan completion. Initial bidirectional cavopulmonary shunt palliation should not be considered as a one-way path to Fontan. Although technically challenging, early- and mid-term clinical results of anatomical repair conversion were satisfactory.

Clinical Outcomes after Anatomic Repair Including Hemi-Mustard Operation in Patients with Congenitally Corrected Transposition of the Great Arteries

Background and Objectives

The aims of this study were to determine the early and late outcomes of anatomic repair of congenitally corrected transposition of the great arteries (ccTGA) and to evaluate effectiveness of the hemi-Mustard procedure.

Subjects and Methods

We conducted a retrospective, single-center study of patients who underwent anatomic repair for ccTGA between July 1996 and December 2013. Sixteen patients were included in the study. The median age at the time of the operation was 3.5 years (range: 0.5-29.7), and the median body weight was 13.3 kg (range: 5.8-54). The median follow-up duration was 7.7 years (range: 0.2-17.4).

Results

Atrial switch was achieved using the Mustard procedure in 12 patients (hemi-Mustard procedure in 11) or the Senning procedure in four patients. The ventriculoarterial procedure was performed using the Rastelli procedure in 11 patients and arterial switch in five patients. Six patients underwent tricuspid valvuloplasty. The survival rate was 93.8±6.1%. The rate of freedom from reoperation at 5 years was 92.3±7.4% in the Rastelli group. All patients except one were New York Heart Association class I. All patients except one had mild tricuspid regurgitation.

Conclusion

Anatomic repair can be performed with a low risk of in-hospital mortality. The hemi-Mustard strategy for selected patients is one solution for reducing early mortality and morbidity, and long-term complications such as venous pathway stenosis or sinus node dysfunction.

One-and-a-half ventricle repair in adult patients: a word of caution

OBJECTIVES

The "one-and-a-half ventricle repair" (1.5 VR) is applied to several congenital heart diseases with hypoplastic right ventricle (RV), with good functional and clinical results in infants and children, but feasibility in adult population is being explored.

MATERIALS AND METHODS

This is a retrospective analysis of medical records of all adult patients undergoing 1 + 1/5 VR between 2000 and 2012.

RESULTS

Five patients (M/F = 4/1, mean age of 42.3 years, range 29-66.8) underwent 1 + 1/5 VR. Underlying diagnoses were Ebstein's anomaly (EA) in three, hypoplastic RV and tricuspid valve (TV) in two. Mean TV annulus Z-score was -3.0; mean pulmonary vascular resistance was 1.6 WU/m(2) . Eleven associated procedures were performed simultaneously to 1.5 VR. There were no operative deaths. All patients were discharged home alive and in good clinical condition on anticoagulation regimen. At a mean follow-up of 8.6 ± 5.2 years, there was one cerebral stroke-related death; two patients experienced major complications. Two patients are in NYHA Class I, one is in NYHA Class II, and the last in NYHA Class III on a transplant list.

CONCLUSIONS

The one-and-a-half ventricle repair in adult patients is feasible with low mortality. However, advanced age-associated co-morbidities and prolonged chronic RV preoperative dysfunction may jeopardize long-term results when compared to children.

One and a half ventricle repair in association with tricuspid valve repair according to "peacock tail" technique in patients with Ebstein's malformation and failing right ventricle

OBJECTIVES

The aim of this study was to evaluate the outcome in a series of patients with Ebstein's anomaly and a failing right ventricle (RV) undergoing tricuspid valve (TV) repair and bidirectional Glenn cavopulmonary anastomosis (BDG).

MATERIALS AND METHOD

Between January 2006 and September 2013, 11 consecutive patients diagnosed with severe forms of Ebstein's anomaly and a failing RV underwent TV surgery and BDG. The mean age was 16.5 ± 7 years. Most frequently found symptoms were cyanosis, dyspnea, and arrhythmias. The azygos or hemiazygos veins were left open. The TV was repaired using the "peacock tail" technique, which consisted of total detachment of the anterior and posterior leaflets of the TV and rotation in both directions reimplanting them to the true annulus. The mean follow-up was 3.8 ± 2.4 years (range three months to six years).

RESULTS

Hospital mortality was 9% (one patient). TV repair was possible in 10 patients. None of the patients had AV block postoperatively. At one year after surgery, the indexed RV and RA diameter were reduced significantly versus the preoperative data (p = 0.003 and p < 0.001). The mean TVR and indexed TV area were 1.2 ± 0.42 and 1.6 ± 0.6 (mm/m2), significantly lower than preoperatively (p = 0.001 and p = 0.008, respectively). The mean NYHA functional class, SaO2 , and cardiothoracic ratio were significantly improved.

CONCLUSIONS

The peacock tail technique for TV repair in combination with BDG in patients with Ebstein's malformation and depressed RV function results in TV preservation, a low incidence of recurrent regurgitation, favorable functional status and RV function, and resolution of cyanosis.

Transcatheter management of neonates with pulmonary atresia with intact ventricular septum: a single center experience from Turkey

Pulmonary atresia with intact ventricular septum (PAIVS) is characterized by a broad spectrum of heterogeneous morphologies. Perforation of the atretic valve, balloon dilatation, and stenting of the patent ductus arteriosus are the percutaneous techniques that are used with increasing frequency in our clinic as well. They have some advantages over surgery, including short hospital stay and short intensive care unit stay. The main goal of the primary interventional approach is to avoid surgery. However, a group of patients with PAIVS still need surgery due to poor right ventricular growth. Therefore, the final achievement of the initial percutaneous treatment strategies is still debatable. In this article, we present the early- and mid-term results of the percutaneous approach utilized at our clinic in order to investigate the final effects of interventional therapy according to initial morphology. Between May 2010 and May 2012, 15 neonates diagnosed with PAIVS underwent transcatheter intervention. Detailed echocardiographic examination focused on right ventricle size, and tricuspid valve morphology and coronary sinusoids were performed in all the patients before the intervention. Nine of the patients were boys and six were girls. The mean age was 11.40 ± 12.87 days and mean weight was 3.34 ± 0.46 kg. Only one procedure-related mortality occurred. The mean follow-up period was 10.05 ± 3.42 months (1-26 months). The mean duration of intensive care was 7.19 ± 5.14 days. The mean follow-up time was 10.05 ± 3.42 months. After this period, survival rate was 66% (10/15). Two of the patients achieved biventricular physiology after pulmonary valve perforation. Two patients still have univentricular physiology. Six patients have been followed as a one and half ventricle repair candidate. Five out of 15 patients had stent patency during 6 months of follow-up, while restenosis developed in one patient (1/5, 20%), who had undergone the Glenn operation at 5 months of age. Transcatheter management for PAIVS is a feasible, safe, and effective primary palliative treatment in newborns. Shunt surgery may be considered in cases where cyanosis occurs despite transcatheter intervention. Right ventricular size determines the type of intervention. The early outcomes can be comparable with surgical palliation. However, a group of PAIVS, particularly with severe right ventricular hypoplasia, needs surgery even after a successful primary percutaneous intervention.

Mid-term results of bidirectional cavopulmonary anastomosis and hemi-Mustard procedure in anatomical correction of congenitally corrected transposition of the great arteries

OBJECTIVES

The Senning or Mustard procedure combined with the arterial switch operation (ASO) (± VSD and no left ventricular (LV) outflow tract obstruction) or the Rastelli operation (VSD and LV outflow tract obstruction) has become the preferred strategy over conventional repair as it is thought to prevent long-term dysfunction of the right ventricle (RV). More recently, hemi-Mustard rerouting of blood from the inferior vena cava to the RV in combination with bidirectional cavopulmonary anastomosis (BCPA) has been adopted by some centres for potential benefits over the classic atrial switch procedure. The aim of this study was to analyse our experience with hemi-Mustard and BCPA as part of an anatomical repair of congenitally corrected transposition of the great arteries (CCTGA) in selected patients.

METHODS

Between 2004 and 2011, eight patients underwent hemi-Mustard/BCPA with the Rastelli operation (n = 6) or ASO (n = 2). The median age was 2.9 (range: 1.2-9.1) years. Positional anomalies were present in 75% of the patients. Both patients with ASO had dysplastic and insufficient tricuspid valves. In the Rastelli group, four patients had previously received shunts followed by BCPA in one patient. In the ASO group, both patients underwent pulmonary artery banding initially.

RESULTS

There was one in-hospital death and no late mortality. Two patients received a pacemaker. One patient from the Rastelli group required conduit change 6 years later. At the mean follow-up of 4.5 years, six and one patients are in NYHA classes I and II, respectively; six patients showed good biventricular function, while one had LV dysfunction. Systemic venous obstruction and sinus node dysfunction were not observed, and BCPA was functioning well in all patients.

CONCLUSIONS

Hemi-Mustard/BCPA is useful in anatomical repair of CCTGA in selected patients. When compared with the classic atrial switch operation, it is technically easier which makes it especially helpful in atrio-apical discordance; it unloads an RV with limited size or function, and avoids complications related to the upper limb of the classic atrial switch procedure. Mid-term results of this approach are favourable. Further follow-up is needed to prove long-term benefits.

Outcomes of biventricular repair for congenitally corrected transposition of the great arteries

BACKGROUND

This study was undertaken to evaluate long-term results of biventricular repairs for congenitally corrected transposition of the great arteries, and to analyze the risk factors that affect mortality and morbidity.

METHODS

Between 1983 and 2009, 167 patients with congenitally corrected transposition of the great arteries underwent biventricular repairs. The physiologic repairs were performed in 123 patients, and anatomic repairs in 44. Average follow-up was 9.3 +/- 6.6 years.

RESULTS

Kaplan-Meier estimated survival was 83.3% +/- 0.5% at 25 years in biventricular repair. In anatomic repair, left ventricular training and right ventricular dysfunction had negative impact on survival, but bidirectional cavopulmonary shunt had positive impact on survival. The reoperation-free ratio was 10.1% +/- 7.8% at 22 years after physiologic repair, and 46.2% +/- 12.4% at 15 years after anatomic repair (p = 0.885). Freedom from any arrhythmia was 49.6% +/- 7.5% at 22 years after physiologic repair, and 60.8% +/- 14.8% at 18 years after anatomic repair (p = 0.458). Freedom from systemic atrioventricular valve and ventricular dysfunction as well as tricuspid valve and right ventricular dysfunction was significantly higher in anatomic repair than in physiologic repair.

CONCLUSIONS

Long-term results of biventricular repair were satisfactory. Patients presenting with right ventricular dysfunction or need for left ventricular training represent a high-risk group of anatomic repair for which selection criteria are particularly important. Late functional outcomes of anatomic repair were excellent compared with physiologic repair. Anatomic repair is the procedure of choice for those patients if both ventricles are adequate or if surgical technique is modified with the help of additional a bidirectional cavopulmonary shunt.

Selective right ventricular unloading and novel technical concepts in Ebstein's anomaly

BACKGROUND

Favorable outcomes in Ebstein's anomaly are predicated on tricuspid valve competence and right ventricular function. Successful valve repair should be aggressively pursued to avoid the morbidity of prosthetic tricuspid valve replacement. We report our experience with valve-sparing intracardiac repair, emphasizing novel concepts and techniques of valve repair supplemented by selective bidirectional Glenn (BDG).

METHODS

Between June 1993 and December 2008, 57 nonneonatal patients underwent Ebstein's anomaly repairs. The median age at operation was 8.1 years. All were symptomatic in New York Heart Association (NYHA) functional class II (n = 38), III (n = 17), or IV (n = 1). Preoperatively, 26 had mild or moderate cyanosis at rest. We used a number of valve reconstructive techniques that differed substantially from those currently described. BDG was performed in 31 patients (55%) who met specific criteria.

RESULTS

No early or late deaths occurred. At the initial repair, 3 patients received a prosthetic valve. Four patients required reoperation for severe tricuspid regurgitation. Repeat repairs were successful in 2 patients. At follow-up (range, 3 months to 6 years), all patients were acyanotic and in NYHA class I. Tricuspid regurgitation was mild or less in 49 (86%) and moderate in 6 (11%). Freedom from a prosthesis was 91% (52 of 57).

CONCLUSIONS

Following a protocol using BDG for ventricular unloading in selected patients with Ebstein's anomaly can achieve a durable valve-sparing repair using the techniques described. Excellent functional midterm outcomes can be obtained with a selective one and a half ventricle approach to Ebstein's anomaly.

Ventricular Volumes in Ebstein’s Anomaly: X-Ray Multislice Computed Tomography Before and After Repair

BACKGROUND

This study was performed to measure right and left ventricular volumes in Ebstein's anomaly before and after operation.

METHODS

Twenty-six consecutive patients were operated on with tricuspid valve repair and plication of the atrialized right ventricle, associated with a bidirectional cavopulmonary shunt in 15 patients. Right ventricular (RV) and left ventricular end-diastolic and end-systolic volume indexes were measured by x-ray computerized tomography before and after surgical repair. Left ventricular stroke index and ejection fraction were calculated.

RESULTS

Before surgery, the mean stroke index of the atrialized RV was 36 +/- 33 mL/m2, with severe reduction in 9 patients and aneurysmal aspect in 2 patients. After surgery, the atrialized RV was no longer identifiable. Both RV end-diastolic volume index and stroke index of the remaining effective RV were reduced. Bidirectional cavopulmonary shunt was a determinant factor of decrease in the effective RV end-diastolic volume index after repair. Conversely, left ventricular ejection fraction and stroke index increased significantly after surgery.

CONCLUSIONS

The atrialized RV with dyskinesia seems a good indication for a plication. RV end-diastolic volume index of the effective RV decreased after surgery. In severe cases, bidirectional cavopulmonary shunt was useful by decreasing RV end-diastolic volume, thus preventing further RV dilation. In all cases left ventricular ejection fraction and stroke volume index increased after surgery.

The hemi-Mustard, bi-directional Glenn, and Rastelli operations used for correction of congenitally corrected transposition, achieving a "ventricle and a half " repair

Based on experience in several centers, the double switch operation has reportedly become the standard surgical therapy for congenitally corrected transposition. We report and discuss here the use of a "ventricle and a half" double switch operation performed due to the concerns raised intraoperatively because of the size of the morphologically right ventricle. Although the long-term course of such a procedure in this setting remains unknown, we submit that the proposed benefits of the double switch operation, even when used in the "ventricle and a half" configuration, may be superior to the alternatives.

One and a half ventricle repair for Ebstein's anomaly

The surgical strategy for patients having Ebstein's anomaly and hypoplastic right ventricle is controversial. An 11-year-old boy patient having such condition, with estimated end-diastolic volume index of the atrialized and functional right ventricle being 70% of normally expected values, underwent biventricular repair. Immediately after the surgery, however, he developed right heart failure with the central venous pressure of 11 mmHg. He consequently underwent additional bidirectional cavopulmonary anastomosis, thereby converting the biventricular repair into one and a half ventricle repair. He recovered uneventfully and is doing well 2 years after the surgery.

Pulmonary atresia with intact ventricular septum: Strategy based on right ventricular morphology

OBJECTIVES

Management strategy for pulmonary atresia with intact ventricular septum is controversial. We treated patients with this anomaly according to a management protocol based on our quantitative assessment of right ventricular morphology (index of right ventricular development and right ventricle-tricuspid valve index). In the present study, we reviewed a 20-year experience of the surgical treatment at our institution to define guidelines for selecting the appropriate type of surgical procedure.

METHODS

Between April 1981 and June 2002, 45 consecutive patients with pulmonary atresia with intact ventricular septum underwent surgical treatment. Open transpulmonary valvotomy was performed in 27 patients and Blalock-Taussig shunt in 18 patients as the initial palliative procedure. Three patients who underwent a successful transpulmonary valvotomy alone in the neonatal period required no further operation. Definitive repair was performed in 32 patients. Biventricular repair was performed on 19 patients, one and a half ventricular repair in 3, and Fontan-type operation in 10.

RESULTS

There were 1 early and 2 late deaths before the definitive operation in patients who underwent transpulmonary valvotomy. Two patients who had coronary artery interruption died 3 months and 13 years after the initial Blalock-Taussig shunt. There were 1 early and 2 late deaths after the definitive operation. Actuarial survival, including noncardiac death, was 91.1% at 5 years after the initial procedure and 81.5% at 10 years.

CONCLUSIONS

We treated patients with pulmonary atresia with intact ventricular septum according to a management protocol based on our quantitative assessment of right ventricular morphology with good results.

One and one half ventricle repairs

Patients with functionally or anatomically borderline pulmonary ventricles can be managed by a biventricular repair, a Fontan procedure, or by an intracardiac repair in association with a cavopulmonary anastomosis. The latter repair is known as a one and one half ventricle repair. Extending the limits of a biventricular repair can be associated with a high early mortality. The Fontan is associated with late failure. One and one half ventricle repairs are an attempt to reduce early risk and late failure while still achieving separate pulmonary and systemic circulations. The two most common reasons for a one and one half ventricle repair are a small pulmonary ventricle and a dilated poorly functioning pulmonary ventricle. Estimated ventricular volumes of 30% to 80% and z values as small as -10 have been successfully repaired with the one and one half ventricle approach. Ebstein's anomaly is the most common situation where dilated and poorly functioning pulmonary ventricles are treated with a one and one half ventricle repair. There are also special situations where the one and one half ventricle repair is logical. Mortality has ranged from 0% to 12%. No intermediate term sequelae of protein loosing enteropathy, atrial arrhythmias, or pulmonary arteriovenous fistula have been identified. Successful one and one half ventricle repairs have primarily been performed for small pulmonary ventricles and poorly functioning pulmonary ventricles such as those seen with Ebstein's anomaly. Intermediate term follow up has been favorable when compared to the Fontan circulation. Copyright 2000 by W.B. Saunders Company

One and a half ventricle repair with pulsatile bidirectional Glenn: results and guidelines for patient selection

BACKGROUND

The guidelines for performing a one and a half ventricle repair with pulsatile bidirectional Glenn remains controversial. This retrospective report summarizes the experience of a single institution, with an attempt at providing an answer.

METHODS

Fifty consecutive patients, aged 4 months to 42 years, underwent intracardiac repair along with a superior cavopulmonary connection. Twenty-seven of the patients had had previous surgical palliation. Repair consisted of patch closure of the ventricular septal defect (n = 25), tricuspid valve repair (n = 26), reconstruction of the right ventricular outflow tract (n = 34), transpulmonary annular patch (n = 34), right ventricle to pulmonary artery homograft conduit (n = 4), and concomitant repair of atrioventricular canal (n = 9). Ten patients were left with a fenestration in the atrial septum.

RESULTS

There were six hospital deaths (12%) and two late deaths (4.5%). Forty-two survivors were followed from 8 months to 116 months. Eighty-eight percent are in functional class I. Actuarial survival at 97 months was 74%.

CONCLUSIONS

Moderate right heart hypoplasia constitutes a safe anatomic category for a pulsatile bidirectional Glenn. It is advisable not to proceed with a one and a half ventricle repair if postoperative residual pulmonary artery hypertension is anticipated. Patients requiring an intricate intracardiac repair and those with concomitant right heart hypoplasia may be better suited for a Fontan type of repair to reduce the complexity of the procedure.

Natural and unnatural history of pulmonary atresia

OBJECTIVE

To investigate mortality, cause of death, survival, and quality of life in all types of cardiac malformation with congenital pulmonary atresia.

DESIGN

Retrospective analysis.

SETTING

The resident population of one health region with a single tertiary referral centre.

PATIENTS

All babies with pulmonary atresia live born in 1980 to 1995.

MAIN OUTCOME MEASURES

Anatomical classification, total mortality, cause of death, duration of survival, exercise ability. All cases were classified as pulmonary atresia with intact septum (PA-IVS), pulmonary atresia with ventricular septal defect (PA-VSD), or pulmonary atresia with complex cardiac malformation (complex pulmonary atresia).

RESULTS

129 cardiac malformations with congenital pulmonary atresia were identified from 601 635 live births (21.4/100 000): 29 had PA-IVS, 60 had PA-VSD, and 40 had complex pulmonary atresia. Total mortality was 72/129 (56%), with 15 deaths in the first week and 49 in the first year. There were 23 surgical deaths, 33 hospital deaths (not related to surgery), and 16 sudden deaths, 12 of which remained unexplained. The sudden death rate was 29/1000 patient years of follow up. Of the 57 survivors, 39% have exercise ability I or II and 61% III or IV. Definitive surgical repair produced better exercise ability.

CONCLUSIONS

Early mortality is high in all types of pulmonary atresia, although survival has improved in recent years. Most children who have not undergone definitive repair have significant exercise limitation.

Pulmonary atresia with intact ventricular septum percutaneous radiofrequency-assisted valvotomy and balloon dilation versus surgical valvotomy and Blalock Taussig shunt

OBJECTIVE

We compared the result of radiofrequency (RF)-assisted valvotomy and balloon dilation with closed surgical valvotomy and Blalock Taussig (BT) shunt as primary treatment in selected patients with pulmonary atresia and intact ventricular septum (PA-IVS).

BACKGROUND

Patients with PA-IVS who have mild to moderate hypoplasia of the right ventricle (RV) and patent infundibulum have the greatest potential for complete biventricular circulation. The use of RF or laser wires to perforate the atretic valve followed by balloon dilation provides an alternative to surgery.

METHODS

Between May 1990 and March 1998, 33 selected patients underwent either percutaneous RF valvotomy and balloon dilation (group 1, n = 21; two crossed over to group 2) or surgical valvotomy with concomitant BT shunt (group 2, n = 14). Second RV decompression by balloon dilation or right ventricular outflow tract (RVOT) reconstruction were performed if necessary. Patients who remained cyanosed were subjected to transcatheter trial closure of the interatrial communication. Partial biventricular repair was offered to those with inadequate growth of the RV.

RESULTS

The primary procedure was successful in 19 patients in group 1. There was one in-hospital death and two late deaths. Of the remaining 16 survivors, 12 achieved complete biventricular circulation, 7 of whom required no further interventions. Two patients required repeat balloon dilation, 1 RVOT reconstruction and 2 transcatheter closure of interatrial communication. Two patients underwent partial biventricular repair. In group 2, there were 3 in-hospital deaths after the primary procedure and 1 patient died four months later. All survivors (n = 10) required a second RV decompression, 8 by balloon dilation and 2 by RVOT reconstruction, after which, two patients died. Of the final 8 survivors, 7 achieved complete biventricular circulation, 5 after coil occlusion of the BT shunt and 2 after closure of interatrial communication.

CONCLUSIONS

Radiofrequency valvotomy and balloon dilation is more efficacious and safe compared with closed pulmonary valvotomy and BT shunt in selected patients with PA-IVS.

The adult patient with Ebstein anomaly. Outcome in 72 unoperated patients

Knowledge of the long-term outcome in unoperated adult patients with Ebstein anomaly is limited, and the therapeutic approach is still controversial. We studied unoperated adult patients with Ebstein anomaly to define the patterns of presentation, anatomic characteristics, outcome, and predictive factors for survival. Seventy-two unoperated survivors of Ebstein anomaly aged over 25 years attended from 1972 to 1997 were reviewed and followed-up from 1.6 to 22.0 years. Patients were classified in 3 groups of severity according to the echocardiographic appearance of the septal leaflet attachment of tricuspid valve. The mean age at diagnosis was 23.9 +/- 10.4 years, and the most common clinical presentation was an arrhythmic event (51.4%). There were 30 (42%) deaths, including 6 from arrhythmia, 12 related to heart failure, 7 sudden, 2 unrelated, and 3 unascertained. According to Cox regression analysis, predictors of cardiac-related death included age at diagnosis (hazard ratio 0.89 for each year of age, 95% confidence intervals CI[ 0.84-0.94), male sex (3.93, 95% CI, 1.50-10.29), degree of echocardiographic severity (3.34, 95% CI, 1.78-6.24), and cardiothoracic ratio > or = 0.65 (3.57, 95% CI, 1.15-11.03). During follow-up, morbidity was mainly related to arrhythmia and refractory late hemodynamic deterioration. The magnitude of tricuspid regurgitation, cyanosis, and the New York Heart Association (NYHA) functional class at time zero were significant risk factors according to the univariate analysis, but not after multivariable confrontation. The results of this study suggest that pattern of presentation, clinical course, and prognosis of unoperated adult patients with Ebstein anomaly are influenced by several factors. Although the initial symptoms are usually mild and commonly related to supraventricular arrhythmias, these are not associated with the long-term outcome. The severity of the morbid anatomy was the main determinant of survival only in extreme cases, but not in those with mild or moderate deformations, which are more common in adults. Other independent risk factors such as cardiothoracic ratio, sex, age at diagnosis, and the echocardiographic evaluation may help to determine the therapeutic approach. Adult patients with Ebstein anomaly should not be considered as a simple low-risk group.

Bidirectional Glenn shunt in association with congenital heart repairs: the 1(1/2) ventricular repair

BACKGROUND

The bidirectional Glenn shunt has been used to incorporate a smaller tripartite ventricle into the circulation and create pulsatile pulmonary artery flow. We reviewed our operative experience and assessed hemodynamics of the bidirectional Glenn shunt in 1(1/2) ventricular repair or in conjunction with other repairs of congenital heart defects.

METHODS

Between 1992 and 1998, 15 patients (mean age, 8.1+/-7.9 years) had bidirectional Glenn shunt in association with repair of congenital heart defects. Eighty-seven percent had at least one previous operation. All patients had simultaneous or previous intracardiac repair and had bidirectional Glenn shunt to volume unload the small right ventricle (group A, n = 7), to unload the poorly functioning right ventricle (group B, n = 2), to redirect superior vena cava-pulmonary venous atrial connection to treat cyanosis (group C, n = 2), or to unload the pulmonary left ventricle for residual intracavitary hypertension in patients with L-transposition of the great arteries, ventricular septal defect, and pulmonary stenosis (group D, n = 4). Intraoperative hemodynamic assessment was done in 2 patients in group A by selective use of inflow occlusion and flow probes.

RESULTS

All patients survived. Four patients had successful, concurrent arrhythmia circuit cryoablation for Wolf-Parkinson-White syndrome (n = 1) or atrial reentry tachycardia (n = 3). Superior and inferior vena caval flow averaged 36% and 64% of cardiac output, respectively. Postoperative superior vena caval pressure (n = 13) was 13.7+/-4.0 mm Hg with pulmonary arterial flow pattern contributed by the ventricle in systole (pulsatile) and the superior vena cava in diastole (laminar).

CONCLUSIONS

The bidirectional Glenn shunt is an effective adjunct to congenital heart repair to treat pulmonary ventricular pressure-volume problems and anomalous superior vena caval to left atrial connections.

Experience with one and a half ventricle repair

OBJECTIVE

This article presents a 10-year experience with one and a half ventricle repair for right ventricular hypoplasia or dysfunction.

METHODS

From November 1986 to December 1996, 30 patients (mean age 6.7 +/- 8.5 years, range 4 months-40 years) with functionally abnormal right ventricles underwent a bidirectional Glenn shunt as part of the repair. Diagnoses included pulmonary atresia with intact ventricular septum (n = 15), Ebstein anomaly (n = 5), levotransposition of the great arteries (n = 3), pulmonary stenosis with right ventricular hypoplasia (n = 2), tetralogy of Fallot (n = 3), dextrotransposition of the great arteries (n = l), and Uhl anomaly (n = l). Concomitantly performed cardiac procedures included atrial septal defect closure (n = 27), fenestration of the atrial septum (n = 2), right ventricular cavity augmentation (n = 8), right ventricular outflow tract enlargement (n = 6), transannular patch (n = 13), modified Blalock-Taussig shunt closure (n = 16), tricuspid replacement (n = 3), tricuspid repair (n = 2), Rastelli procedure (n = 3), tricuspid commissurotomy (n = 2), and double switch (n = l).

RESULTS

There were 2 early deaths (6.6%) and 1 late death. Mean early postoperative superior vena caval pressure was 14. 12 +/- 3.55 mm Hg and mean right atrial pressure was 10.3 +/- 5.16 mm Hg. Early oxygen saturation in the operating room with an inspired oxygen fraction of 1 was 97.2 +/- 2.5; oxygen saturation was 92.3 +/- 4.8 on room air at discharge. Mean oxygen saturations were 93.6% +/- 3.6% at 1 year of follow-up (P =.10) and 93.5% +/- 4. 1% at 5 years (P =.12). Overall survival was 90% at 5 years, and 21 patients (77%) were in New York Heart Association class I, 5 (18%) were in class II, and 1 (2.7%) was in class III.

CONCLUSION

This procedure provides a valid alternative for correction of right ventricle hypoplasia or dysfunction. Early and intermediate follow-up results compare favorably with those of the Fontan procedure, but long-term follow-up is needed.

Evaluation and management of pulmonary atresia with intact ventricular septum

Pulmonary atresia with intact ventricular septum (PA/IVS) is a spectrum of diseases with varying severity of right ventricle hypoplasia and potential for biventricular, univentricular, or hybrid repairs. Pessimistic outcome measures for PA/IVS may give way to optimism with the refinement of early diagnosis and early intervention to encourage right ventricle flow and optimize growth. To this end, PA/IVS has become a focus of innovative interventions (e.g., fetal surgery) and new catheter-based and surgical techniques.