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Cantinotti M, Jani V, Kutty S, Marchese P, Franchi E, Pizzuto A, Viacava C, Assanta N, Santoro G, Giordano R. Neonates and Infants with Left Heart Obstruction and Borderline Left Ventricle Undergoing Biventricular Repair: What Do We Know about Long-Term Outcomes? A Critical Review. Healthcare (Basel) 2024; 12:348. [PMID: 38338232 PMCID: PMC10855671 DOI: 10.3390/healthcare12030348] [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: 11/20/2023] [Revised: 01/22/2024] [Accepted: 01/23/2024] [Indexed: 02/12/2024] Open
Abstract
BACKGROUND The decision to perform biventricular repair (BVR) in neonates and infants presenting with either single or multiple left ventricle outflow obstructions (LVOTOs) and a borderline left ventricle (BLV) is subject to extensive discussion, and limited information is known regarding the long-term outcomes. As a result, the objective of this study is to critically assess and summarize the available data regarding the prognosis of neonates and infants with LVOTO and BLV who underwent BVR. METHODS In February 2023, we conducted a review study with three different medical search engines (the National Library of Medicine, Science Direct, and Cochrane Library) for Medical Subject Headings and free text terms including "congenital heart disease", "outcome", and "borderline left ventricle". The search was refined by adding keywords for "Shone's complex", "complex LVOT obstruction", "hypoplastic left heart syndrome/complex", and "critical aortic stenosis". RESULTS Out of a total of 51 studies, 15 studies were included in the final analysis. The authors utilized heterogeneous definitions to characterize BLV, resulting in considerable variation in inclusion criteria among studies. Three distinct categories of studies were identified, encompassing those specifically designed to evaluate BLV, those focused on Shone's complex, and finally those on aortic stenosis. Despite the challenges associated with comparing data originating from slightly different cardiac defects and from different eras, our results indicate a favorable survival rate and clinical outcome following BVR. However, the incidence of reintervention remains high, and concerns persist regarding residual pulmonary hypertension, which has been inadequately investigated. CONCLUSIONS The available data concerning neonates and infants with LVOTO and BLV who undergo BVR are inadequate and fragmented. Consequently, large-scale studies are necessary to fully ascertain the long-term outcome of these complex defects.
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Affiliation(s)
- Massimiliano Cantinotti
- Foundation G. Monasterio CNR-Regione Toscana, 56124 Pisa, Italy; (M.C.); (P.M.); (E.F.); (A.P.); (C.V.); (N.A.); (G.S.)
| | - Vivek Jani
- Helen B. Taussig Heart Center, Department of Pediatrics, Johns Hopkins Hospital, Baltimore, MD 21205, USA; (V.J.); (S.K.)
| | - Shelby Kutty
- Helen B. Taussig Heart Center, Department of Pediatrics, Johns Hopkins Hospital, Baltimore, MD 21205, USA; (V.J.); (S.K.)
| | - Pietro Marchese
- Foundation G. Monasterio CNR-Regione Toscana, 56124 Pisa, Italy; (M.C.); (P.M.); (E.F.); (A.P.); (C.V.); (N.A.); (G.S.)
| | - Eliana Franchi
- Foundation G. Monasterio CNR-Regione Toscana, 56124 Pisa, Italy; (M.C.); (P.M.); (E.F.); (A.P.); (C.V.); (N.A.); (G.S.)
| | - Alessandra Pizzuto
- Foundation G. Monasterio CNR-Regione Toscana, 56124 Pisa, Italy; (M.C.); (P.M.); (E.F.); (A.P.); (C.V.); (N.A.); (G.S.)
| | - Cecilia Viacava
- Foundation G. Monasterio CNR-Regione Toscana, 56124 Pisa, Italy; (M.C.); (P.M.); (E.F.); (A.P.); (C.V.); (N.A.); (G.S.)
| | - Nadia Assanta
- Foundation G. Monasterio CNR-Regione Toscana, 56124 Pisa, Italy; (M.C.); (P.M.); (E.F.); (A.P.); (C.V.); (N.A.); (G.S.)
| | - Giuseppe Santoro
- Foundation G. Monasterio CNR-Regione Toscana, 56124 Pisa, Italy; (M.C.); (P.M.); (E.F.); (A.P.); (C.V.); (N.A.); (G.S.)
| | - Raffaele Giordano
- Adult and Pediatric Cardiac Surgery, Department of Advanced Biomedical Sciences, University of Naples “Federico II”, 80131 Naples, Italy
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Brüning J, Kramer P, Goubergrits L, Schulz A, Murin P, Solowjowa N, Kuehne T, Berger F, Photiadis J, Weixler VHM. 3D modeling and printing for complex biventricular repair of double outlet right ventricle. Front Cardiovasc Med 2022; 9:1024053. [PMID: 36531701 PMCID: PMC9748612 DOI: 10.3389/fcvm.2022.1024053] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Accepted: 11/07/2022] [Indexed: 02/06/2024] Open
Abstract
BACKGROUND Double outlet right ventricle (DORV) describes a group of congenital heart defects where pulmonary artery and aorta originate completely or predominantly from the right ventricle. The individual anatomy of DORV patients varies widely with multiple subtypes classified. Although the majority of morphologies is suitable for biventricular repair (BVR), complex DORV anatomy can render univentricular palliation (UVP) the only option. Thus, patient-specific decision-making is critical for optimal surgical treatment planning. The evolution of image processing and rapid prototyping techniques facilitate the generation of detailed virtual and physical 3D models of the patient-specific anatomy which can support this important decision process within the Heart Team. MATERILAS AND METHODS The individual cardiovascular anatomy of nine patients with complex DORV, in whom surgical decision-making was not straightforward, was reconstructed from either computed tomography or magnetic resonance imaging data. 3D reconstructions were used to characterize the morphologic details of DORV, such as size and location of the ventricular septal defect (VSD), atrioventricular valve size, ventricular volumes, relationship between the great arteries and their spatial relation to the VSD, outflow tract obstructions, coronary artery anatomy, etc. Additionally, physical models were generated. Virtual and physical models were used in the preoperative assessment to determine surgical treatment strategy, either BVR vs. UVP. RESULTS Median age at operation was 13.2 months (IQR: 9.6-24.0). The DORV transposition subtype was present in six patients, three patients had a DORV-ventricular septal defect subtype. Patient-specific reconstruction was feasible for all patients despite heterogeneous image quality. Complex BVR was feasible in 5/9 patients (55%). Reasons for unsuitability for BVR were AV valve chordae interfering with potential intraventricular baffle creation, ventricular hypoplasia and non-committed VSD morphology. Evaluation in particular of qualitative data from 3D models was considered to support comprehension of complex anatomy. CONCLUSION Image-based 3D reconstruction of patient-specific intracardiac anatomy provides valuable additional information supporting decision-making processes and surgical planning in complex cardiac malformations. Further prospective studies are required to fully appreciate the benefits of 3D technology.
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Affiliation(s)
- Jan Brüning
- Institute for Cardiovascular Computer-Assisted Medicine, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Partner Site Berlin, German Center for Cardiovascular Research (DZHK), Berlin, Germany
| | - Peter Kramer
- Department of Congenital Heart Disease/Pediatric Cardiology, German Heart Center Berlin, Berlin, Germany
| | - Leonid Goubergrits
- Institute for Cardiovascular Computer-Assisted Medicine, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Einstein Center Digital Future, Berlin, Germany
| | - Antonia Schulz
- Department of Congenital Heart Surgery and Pediatric Heart Surgery, German Heart Center Berlin, Berlin, Germany
- Berlin Institute of Health (BIH), Berlin, Germany
| | - Peter Murin
- Department of Congenital Heart Surgery and Pediatric Heart Surgery, German Heart Center Berlin, Berlin, Germany
| | - Natalia Solowjowa
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany
| | - Titus Kuehne
- Institute for Cardiovascular Computer-Assisted Medicine, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Partner Site Berlin, German Center for Cardiovascular Research (DZHK), Berlin, Germany
- Department of Congenital Heart Disease/Pediatric Cardiology, German Heart Center Berlin, Berlin, Germany
| | - Felix Berger
- Partner Site Berlin, German Center for Cardiovascular Research (DZHK), Berlin, Germany
- Department of Congenital Heart Disease/Pediatric Cardiology, German Heart Center Berlin, Berlin, Germany
| | - Joachim Photiadis
- Department of Congenital Heart Surgery and Pediatric Heart Surgery, German Heart Center Berlin, Berlin, Germany
| | - Viktoria Heide-Marie Weixler
- Partner Site Berlin, German Center for Cardiovascular Research (DZHK), Berlin, Germany
- Department of Congenital Heart Surgery and Pediatric Heart Surgery, German Heart Center Berlin, Berlin, Germany
- Berlin Institute of Health (BIH), Berlin, Germany
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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: 3] [Impact Index Per Article: 1.5] [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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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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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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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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Emani SM. Biventricular Repair in Patients With Borderline Left Heart—The “Growing” Experience. World J Pediatr Congenit Heart Surg 2019; 10:18-19. [DOI: 10.1177/2150135118819418] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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