Designing therapeutic strategies for patients with a dominant left ventricle, discordant ventriculo-arterial connections, and unobstructed flow of blood to the lungs

Arterial Switch, Ventricular Septation, and Fontan Takedown for Double Inlet Left Ventricle

A patient with double inlet left ventricle with transposition of great arteries and severe coarctation of the aorta received aortoplasty and pulmonary artery banding, followed by bidirectional Glenn shunt and extracardiac total cavopulmonary connection (TCPC). Severe subaortic stenosis and increased atrioventricular valve regurgitation were noted 4 years after TCPC. Surgery included alleviation of the subaortic stenosis, ventricular septation through the tricuspid valve approach, and an arterial switch with the main pulmonary artery reopened. The TCPC was taken down with both caval veins reconnected to the right atrium; the neopulmonary artery was reconstructed. Biventricular conversion from TCPC was achieved.

Palliative procedures for congenital heart defects

Although total repair of some congenital heart defects is possible in young children, palliative procedures still play an important role in relieving patients' symptoms, particularly in emergent settings, when total correction or surgical repair is not available. However, the concepts and taxonomies of the palliative procedures for congenital heart diseases sometimes seem to be ambiguous and confusing for young cardiac surgeons and cardiologists. This article gives a full-scope overview of the concepts, categories, indications, historical developments and clinical outcomes of the palliative procedures for congenital heart defects that have been documented in the literature. In total, there are 21 palliative procedures for the surgical management of congenital heart defects, which can be classified into four categories: firstly, increasing pulmonary artery flow for pulmonary oligaemia (including shunt procedures); secondly, decreasing pulmonary artery flow for pulmonary overcirculation (pulmonary banding and Norwood procedure); thirdly, enhancing intracardiac blood-oxygen mixture for systemic hypoxaemia (atrial septostomy subjected to different techniques); and, finally, other procedures, including congenital mitral or aortic stenosis palliation, coarctation of aorta palliation and hybrid palliative procedures for hypoplastic left heart syndrome. Modified Blalock-Taussig's and Glenn's shunts and pulmonary artery banding represent the pre-eminent palliative procedures for congenital heart defects and have been proven to be satisfactory after long-term clinical application. It seems that there is a growing trend towards the use of interventional techniques with stent deployment as an alternative to the surgical approach.