DOI: 10.1016/j.athoracsur.2006.05.124 2006;82:2227-2232 Ann Thorac Surg
Andrew Shin, William Regan, Rodrigo Gonzalez and Frank Pigula Meena Nathan, David Rimmer, Pedro J. del Nido, John E. Mayer, Emile A. Bacha,
Ventricular Septal Defect: Results of Primary Biventricular Repair in NeonatesAortic Atresia or Severe Left Ventricular Outflow Tract Obstruction with
http://ats.ctsnetjournals.org/cgi/content/full/82/6/2227located on the World Wide Web at:
The online version of this article, along with updated information and services, is
Print ISSN: 0003-4975; eISSN: 1552-6259. Southern Thoracic Surgical Association. Copyright © 2006 by The Society of Thoracic Surgeons.
is the official journal of The Society of Thoracic Surgeons and theThe Annals of Thoracic Surgery
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mile A. Bacha, MD, Andrew Shin, MD, William Regan, MS, Rodrigo Gonzalez, MD,nd Frank Pigula, MD
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Background. Aortic atresia or severe aortic stenosis andeft ventricular outflow tract obstruction is a frequentomponent of complex congenital heart disease. Aortictresia or severe aortic stenosis and left ventricular out-ow tract obstruction with two adequate ventricles isometimes treated by Norwood palliation followed byate biventricular repair. We reviewed our experienceith primary biventricular repair in this group ofeonates.Methods. Retrospective review identified 17 neonates
10 males) with aortic atresia or severe left ventricularutflow tract obstruction with ventricular septal defectnd an adequate left ventricle undergoing primaryiventricular repair between 1986 and 2002. Mean ageas 7.7 � 2.9 days, weight 3.3 � 0.7 kg, and body surface
rea 0.21 � 0.04 kg/m2. Associated anomalies includedrch hypoplasia, 7 (41%); aortic atresia, 7 (41%); andoarctation, 5 (29%). Results are reported as mean �
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2006 by The Society of Thoracic Surgeonsublished by Elsevier Inc
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Results. Median follow-up was 6 years (range, 1 to 17.7ears). Three of the 17 (18%) died within 30 days. Thereere no deaths in this series since 1992. Nine patients
38.9%) required one reoperation, 7 of which were foronduit stenosis, 1 for left ventricular outflow tract ob-truction, and 1 for residual ventricular septal defect witheft ventricle–to–right atrium shunt. Freedom from deatht 10 years was 82% by Kaplan–Meier estimate.Conclusions. Excellent long-term survival can be
chieved by primary biventricular repair as corrobo-ated by our survival rate of 82%. Primary biventricularepair is an effective operation for aortic atresia andevere left ventricular outflow tract obstruction withdequate sized left ventricle that avoids interstagettrition associated with Norwood palliation and is ourrocedure of choice.
(Ann Thorac Surg 2006;82:2227–32)
© 2006 by The Society of Thoracic Surgeonsypoplastic left heart syndrome includes a widespectrum of cardiac malformations with varying
egrees of underdevelopment of the structures of the lefteart and aorta. At one end of the spectrum is completetresia of aortic and mitral valves and a diminutive leftentricle (LV) incapable of supporting the systemic cir-ulation. At the other end of the spectrum are milderorms of aortic stenosis and mitral stenosis with a rea-onable sized LV. Depending on the severity of thebstructive lesions, surgical management of neonatesith hypoplastic left heart structures [1] involves one of
hree options: (1) Norwood palliation, (2) cardiac trans-lantation, or (3) biventricular repair (BVR).Aortic atresia (AA) or severe LV outflow tract obstruc-
ion (LVOTO) with an associated ventricular septal defectVSD) in the presence of an adequate LV is an infrequentombination. The management strategy for this rare
ccepted for publication May 18, 2006.
resented at the Poster Session of the Forty-second Annual Meeting ofhe Society of Thoracic Surgeons, Chicago, IL, Jan 30–Feb 1, 2006.
ddress correspondence to Dr Pigula, Department of Cardiac Surgery,
roup of lesions clearly depends on the adequacy of theV inflow, ie, the mitral valve dimensions, as well as thedequacy of the LV chamber dimensions. The treatmentptions for this group of lesions involve one of theollowing:
1) Staged approach: initial Norwood followed bydelayed BVR. The second stage in this approachconsists of baffling of the LV to the Stansel con-nection (main pulmonary artery [PA] to aorticanastomosis), establishment of right ventricular(RV) to PA connection, closure of the atrial septaldefect, and takedown of the systemic to PA shunt.The disadvantages of this staged procedure is theexistence of a parallel circulation with its resultantvolume overload, and the assumption of risksassociated with the shunted single ventricle circu-lation that results in interstage attrition of 4% to16% [2, 3].
2) Primary BVR: This approach consists of a Stanselanastomosis with arch augmentation as necessary.The VSD baffles LV output through both the aorticand pulmonary valves into the systemic circula-
tion. An RV to PA homograft completes the repair.0003-4975/06/$32.00doi:10.1016/j.athoracsur.2006.05.124
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2228 NATHAN ET AL Ann Thorac SurgPRIMARY BIVENTRICULAR REPAIR IN NEONATES 2006;82:2227–32
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This approach was first described by Yasui [4]. Theclear advantage of neonatal BVR is the early es-tablishment of circulation in series. Subjecting ahypoplastic LV to normal or near normal preloadallows for postnatal growth toward normal [5–7].
Decision-making involves careful assessment of pre-perative studies including echocardiogram or catheter-
zation data with special attention paid to the size of theitral valve, LV dimensions, the position of the VSD, and
ikely path of the LV to pulmonary valve baffle and itsffect on the ventricular outflow tracts. We reviewed ourxperience with primary BVR in this group of neonates.
atients and Methods
e undertook a retrospective chart review, which re-ealed 17 neonates (10 males) with AA or severe LVOTOnd VSD who had undergone primary BVR between 1986nd 2002 at Children’s Hospital, Boston. This retrospec-ive chart review was approved by the Institutionaleview Board at Children’s Hospital, and parental con-ent was waived. All data were procured according touidelines established by the committee on clinical
nvestigation.All patients’ preoperative studies including echocar-
iograms and catheterization studies were reviewed. Theollowing data were obtained from the preoperativechocardiograms: mitral valve diameter (anteroposteriornd lateral), aortic valve diameter, aortic root diameter,ortic arch (transverse arch) diameter, LV and RV lengthn the four-chamber view, and corresponding calculated
scores. Special attention was paid to mitral valve andV dimensions as these were considered the primaryeterminants of suitability for BVR. The VSD size and
ocation was also documented.All charts were reviewed for operative variables. Vari-
bles of interest included patient survival, procedureerformed, cardiopulmonary bypass times, aortic cross-lamp times, circulatory arrest times, and homograft size.ostoperative variables of interest were length of inten-ive care unit stay, length of hospital stay, duration ofentilatory support, surgical and catheter reinterven-ions, surgical complications, and length of follow-up.
Follow-up data were obtained by review of hospitalnd clinic charts and databases. Details of follow-uplinic visits, echocardiograms and catheterization, andeoperations were obtained and reviewed.
Results are reported as mean � standard deviation.robabilities of survival and freedom from reoperationere estimated using the Kaplan–Meier method.
esults
atient demographics and diagnoses are outlined inables 1 and 2. There were 10 males and 7 females. Meange at operation was 7.7 � 2.9 days, mean weight was 3.3
0.7 kg, and mean body surface area was 0.21 � 0.04g/m2. All 17 patients had a VSD and some form of
VOTO. Seven (41%) had AA and 10 (59%) had aortic lats.ctsnetjournDownloaded from
tenosis or sub–aortic stenosis. Associated anomaliesncluded arch hypoplasia in 7 (41%), coarctation in 741%), and interrupted aortic arch in 5 (29%).
All patients had preoperative echocardiograms. Fouratients had preoperative cardiac catheterization to fur-
her delineate anatomy. The average LV long-axis di-ension was 29.5 � 3.8 mm with a mean z score of �0.09.
imilarly the average mitral valve diameter was 9.79 �.5 mm with a mean z score of �1.26,, all indicative ofdequacy of LV inflow and chamber to support a BVR.igures 1 and 2 depict representative preoperative im-ges. Preoperative echocardiographic data are presentedn Table 2.
All of the patients had a Yasui operation [4] as de-cribed above (Fig 3). Aortic cross-clamp time was 96inutes (range, 65 to 134 minutes), circulatory arrest timeas 65 minutes (range, 13 to 135 minutes), and cardio-ulmonary bypass time was 211 minutes (range, 144 to65 minutes). Homograft size was 10.96 � 2.67 mmrange, 7 to 17 mm). Duration of mechanical ventilationas 7 days (range, 1 to 20 days), average intensive carenit stay was 13 days (range, 2 to 33 days), and totalospital stay was 20 days (range, 6 to 57 days). Median
ollow-up was 6 years (range, 1 to 17.7 years). Nineatients (53%) required one reoperation, 7 of which were
or conduit stenosis. There was only one reoperation forVOTO and one for a residual VSD resulting in an LV toight atrial shunt. In addition 3 patients in this group of 9ad arch narrowing that required surgical intervention at
he time of their first reoperation. One patient had aesidual VSD closed at the time of conduit change. In thisroup of 9 patients, 4 required a second reoperation foronduit stenosis, 1 required a third reoperation for con-uit replacement, and 1 required a fourth reoperation foronduit revision. The diagnoses at reoperation are rep-esented in Table 3, and complications in Table 4.
There were 3 early deaths, all secondary to biventricu-ar failure. All patients had AA and hypoplastic aorticrch with normal z score for mitral valve and LV dimen-ions. The first patient died within 24 hours of biventricu-
able 1. Diagnosis
iagnosisAortic atresia 7 (41%)AS/sub-AS 3 (18%)IAA, AS/sub-AS 5 (29%)DORV/sub-AS 2 (12%)dditional defectsArch hypoplasia 6 (35%)Coarctation 7 (41%)ASD 6 (35%)Discontinuous PA 1 (6%)Thymic aplasia 3 (18%)Prematurity 1 (6%)
S � aortic stenosis; ASD � atrial septal defect; DORV � double-utlet right ventricle; IAA � interrupted aortic arch; PA � pulmo-ary artery.
ar failure and pseudomonas bacteremia. The second
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atient died 28 days postoperatively of biventricularailure leading to multisystem organ failure. Of note, theostoperative course was complicated by Enterobacterpp sepsis. The third patient died on postoperative day 2f biventricular failure. All 3 patients had autopsies,hich revealed no evidence of obstruction to coronaryow, no residual VSD, no obstruction in the LV toeoaortic pathway, and no evidence of arch obstruction.ll deaths occurred in the first 6 years of the studyeriod.Nine patients had follow-up catheterization and inter-
entions, which included dilatation of coarctation (8nterventions), conduit dilatation or stenting (11 inter-entions), and branch PA dilatation or stenting (8 inter-entions). Only 3 of the 14 survivors have had no catheterr surgical reintervention (18%) with a mean follow-up of.5 years in the survivors. Freedom from death byaplan–Meier estimate at 10 years was 82% (Fig 4).
omment
ypoplasia of the left heart falls along an anatomicpectrum that may include hypoplasia of the mitral
ig 1. Preoperative cardiac catheterization of atretic ascending aorta
able 2. Preoperative Echocardiographic Data
ariable Mean � SD
ge 7.7 � 2.9 dayseight 3.3 � 0.7 kg
SA 0.21 � 0.04 kg/mV diameter (mm) 9.79 � 3.5V diameter (mm) 3.71 � 1.59ortic arch (mm) 3.94 � 0.97V long axis (diastole) (mm) 29.5 � 3.8
V � aortic valve; BSA � body surface area; Indexed Mean � mtandard deviation.
ith coronary arteries well outlined. t
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alve, LV, aortic valve, and aorta. In its most severeorm, hypoplastic left heart syndrome, severe hypopla-ia of these structures renders the left heart incapablef supporting the systemic circulation, and requirestaged palliation. In less severe forms, in which aorticalve or aortic hypoplasia exists in the presence ofdequate LV and mitral valve dimensions [8 –10], theeft heart may be suitable for inclusion into the sys-emic circulation.
Two surgical strategies are pursued in the treatment ofhese patients. One strategy favors a staged approach inhich initial palliation is provided by a stage I operation,
ollowed by subsequent consideration of a BVR. Thelternate approach is primary BVR as a neonate.The potential advantages of primary BVR include early
ormalization of physiology, without assumption of riskssociated with the palliated single ventricle. Although ineneral these patients do not have significant hypoplasiaf the LV, and possess more cardiovascular reserve thanatients with classic hypoplastic left heart syndrome, thehunted circulation remains unstable relative to a biven-ricular circulation.
ig 2. Preoperative cardiac catheterization depicting ventricular sep-
Preoperative Echocardiographic Data
Indexed Mean � SD z Score
46.4 � 18.78 �1.2617.3 � 6.9 �3.8718.7 � 5.03 �2.28140 � 3.14 �0.09
dexed to BSA; LV � left ventricle; MV � mitral valve; SD �
2
al defect (VSD).
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The operative approach to primary BVR was firstublished by Yasui and colleagues [4]. The VSD isatched to both semilunar valves, the arch is enlarged asecessary, and a homograft is placed between the RV and
he PAs. Although some authors have suggested an REVodification [11] to this procedure, thus avoiding the
lacement of a homograft between the RV and the PAs, its our opinion that a valved conduit is important, espe-ially in the early postoperative period.
The decision to proceed to neonatal BVR depends onccurate and precise preoperative anatomic information.
able 3. Reoperations
Reoperations (n � 16)
First reoperation, n � 9 (53%)Conduit revision 7 (41%)LVOTO (VSD revision) 1 (6%)Arch plasty 3 (18%)Branch PA plasty 3 (18%)PFO closure 2 (12%)Residual VSD closure 2 (12%)TV plasty 1 (6%)
Second reoperation, n � 4 (23%)Conduit revision 4 (23%)PA plasty 1 (6%)ASD closure 1 (6%)
Third reoperation, n � 1 (6%)Conduit revision 1 (6%)
Fourth reoperation, n � 1 (6%)Conduit revision 1 (6%)
SD � atrial septal defect; LVOTO � left ventricular outflow tract
ig 3. Yasui procedure consisting of a Stanselonnection and arch augmentation, ventriculareptal defect baffle of left ventricle to pulmo-ary artery, and right ventricle to pulmonaryrtery valved conduit.
bstruction; PFO � patent foramen ovale; PA � pulmonary ar-ery; TV � tricuspid valve; VSD � ventricular septal defect. A
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he ability of a hypoplastic LV to support the systemicirculation in the presence of critical aortic stenosisequires that the mitral valve dimensions and LV end-iastolic dimensions be near normal.Schwartz and associates [12] found that the presence ofmoderate to large VSD, unicommissural aortic valves,
ypoplastic mitral valve (z scores � �2), and hypoplasticV with low LV end-diastolic volume (z scores � �2)ere risk factors for failure of BVR in multiple left heartbstructive lesions. Although the patients in the currenteport had very abnormal aortic valves, the mitral valvend LV dimensions fell within the normal range (�2 � zcores � 2). Even in the setting of modest LV hypoplasia,here appears to be the potential for LV growth [5–7, 13].
cElhinney and colleagues [5] in their review of 113eonates who had undergone balloon valvuloplasty wereble to demonstrate that LV end-diastolic dimensionsormalized within the first 1 to 2 years of life. It has been
able 4. Complications
Complications (n � 11)Seizures 3 (18%)Residual VSD 2 (12%)Transient ischemic attack 1 (6%)Mediastinitis 1 (6%)Residual ASD 1 (6%)Sepsis 1 (6%)Subglottic stenosis 1 (6%)Phrenic nerve palsy 1 (6%)
Death (n � 3)Biventricular failure 3 (18%)Gram-negative sepsis 2 (12%)
SD � atrial septal defect; VSD � ventricular septal defect.
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hown that as complete relief as possible of LVOTO at allevels should be the goal of intervention [13–15]. Theserinciples and observations underlie the ongoing effortselated to aggressive recruitment of the LV into theystemic circulation, even during the fetal period [6, 7].
If, after anatomic evaluation, the patient is deemeduitable for BVR, the choice between primary or stagedepair must be made. Pearl and associates [16] reportedheir series of 8 neonates undergoing staged repair to aiventricular circulation. Six of 8 underwent successfulVR at an average age of 7 months, with 1 awaiting repairnd 1 palliated to a Glenn shunt.In a series of 28 neonates with interrupted aortic arch
eported by Erez and coworkers [17], 13 had severeVOTO and were palliated with a stage I procedure, witho operative deaths. However 2 patients required arte-iopulmonary shunt revision within 1 month of initialalliation, and 2 patients with DiGeorge syndrome diedf infection. Six of the survivors went on to undergo BVR3 after bidirectional Glenn operation). One patient had aontan operation, and 5 patients are awaiting definitiveurgery with a bidirectional Glenn.
Ohye and colleagues [18] compared staged versusrimary BVR in a cohort of 20 patients with AA and VSDnd showed no statistical difference, with an actuarialurvival at 5 years of 89% for the staged repair and 73%or the BVR. The authors recommended BVR as thereferred approach. Our current report, documenting2% survival at 10 years, supports a calculation evenore favorable to primary BVR.Interstage period of the shunted single-ventricle circu-
ation remains a vulnerable time for the child. Althoughnterstage mortality for patients with true hypoplastic lefteart syndrome has been reported to be as high as 15%,atients presenting with a normal or near normal LV areot immune. Daebritz and associates [19] compared theiresults of traditional Norwood procedure for hypoplastic
ig 4. Kaplan–Meier curves of freedom from death and reoperationt 10 years; the number at risk at each time interval is depictedbove the x-axis. The top row of numbers indicates risk for deathnd bottom row the risk for reoperation at each time interval.
eft heart syndrome versus primary BVR in a second
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roup with left-side obstructions at different levels butith near normal LV (LV long axis was 80% of the long
xis of the heart) prospectively. They had 10 patients whonderwent staged palliation with 1 early death and 2
nterstage deaths. All 3 patients in the primary BVRroup did well at 1 year of follow-up. This experiencerovides an additional motivation to pursue primaryepair, avoiding the potential disadvantages associatedith the palliated single-ventricle circulation [20–22].The3 deaths in this series occurred early as a result of
iventricular failure. All of these patients had a verymall ascending aorta, and coronary ischemia must beonsidered a likely factor. It should be noted that since992, there have been no deaths in patients undergoingrimary neonatal repair, and the long-term survival isratifying. Although reoperation is unavoidable whenursuing either approach, homograft replacement is rel-tively straightforward and low risk.In summary, primary BVR of neonates with AA or
evere LVOTO results in excellent 10-year survival. Thispproach avoids a vulnerable period associated with thehunted single ventricle. When the anatomy allows, thiss our preferred approach to the surgical management ofhese patients.
e would like to thank Kimberley Gauvreau, ScD, for assistanceith statistics.
eferences
1. Morell VO, Quintessenza JA, Jacobs JP. Biventricular repairin the management of hypoplastic left heart syndrome.Cardiol Young 2004;14(Suppl 1):101–4.
2. Daebritz SH, Nollert GD, Zurakowski D, et al. Results ofNorwood stage I operation: comparison of hypoplastic leftheart syndrome with other malformations. J Thorac Cardio-vasc Surg 2000;119:358–67.
3. Mahle WT, Spray TL, Gaynor JW, Clark BJ 3rd. Unexpecteddeath after reconstructive surgery for hypoplastic left heartsyndrome. Ann Thorac Surg 2001;71:61–5.
4. Yasui H, Kado H, Nakano E, et al. Primary repair of inter-rupted aortic arch and severe aortic stenosis in neonates.J Thorac Cardiovasc Surg 1987;93:539–45.
5. McElhinney DB, Lock JE, Keane JF, Moran AM, Colan SD.Left heart growth, function, and reintervention after balloonaortic valvuloplasty for neonatal aortic stenosis. Circulation2005;111:451–8.
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8. Tchervenkov CI, Tahta SA, Jutras LC, Beland MJ. Biventricu-lar repair in neonates with hypoplastic left heart complex.Ann Thorac Surg 1998;66:1350–7.
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or Research and Education
s the end of the year approaches, it is time to reflect onhe past year and the support we have received. Over theast 15 years, the Thoracic Surgery Foundation for Re-earch and Education (TSFRE) has been the recipient ofonsiderable generosity from the thoracic surgery com-unity. Please know that TSFRE is most grateful to you
or your past commitment to the organization and to theuture of our specialty.
In return for that support, TSFRE has been able toupport an array of research programs and we haverovided important public policy education opportuni-
ies for hundreds of thoracic surgeons.In 2001, the TSFRE initiated a partnership with theational Heart Lung and Blood Institute to provide
ignificant five-year research awards to some of our mostutstanding young surgeon-scientists. In 2004, we estab-
ished a similar partnership with the National Cancernstitute that promises equally exciting research for di-gnosis and treatment of cancer. These partnerships offerremendous benefits to the future of thoracic surgery ando the treatment of our patients.
In 2007, TSFRE will be expanding our educationalctivities by hosting a Visioning Simulation Conferenceo bring together leaders of the specialty with invitedimulation experts and others who would be interested inelping to create a strategic plan for the initiative. Theonference will be held at the Center for Simulation inambridge, Massachusetts, and invited participants will
es and associations, interested government agencies,otential funders from the private foundation commu-ity, leaders in simulation education and others. Theonference will provide a forum for interested parties tollow for a shared vision regarding the development andse of simulation in thoracic surgical education andertification.
In considering your philanthropic support as the yearnds, we would ask you to continue to support the TSFREt least as generously as you have in the past or perhapsonsider increasing your annual gift. Without your sup-ort neither the research nor the educational endeavorsould have been possible.Those over 70½ who are taking a required withdrawal
rom an IRA and are also contributing funds to charityhould strongly consider taking advantage of tax-freeifts from their IRAs this year and next. On August 17,006, The Pension Protection Act was signed into law.his new law would allow qualified taxpayers to donateoney to TSFRE directly from their traditional Roth IRA
ccount. Distributions are tax-free and early withdrawalenalties are avoided. Check with your financial advisorsbout the best ways to take advantage of this new givingpportunity.If you would like to make a pledge or receive more
nformation about giving to TSFRE, please visit www.SFRE.org or call Donna Kohli, the Executive Director of
SFRE, at 978-927-8330.Ann Thorac Surg 2006;82:2232 • 0003-4975/06/$32.00
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DOI: 10.1016/j.athoracsur.2006.05.124 2006;82:2227-2232 Ann Thorac Surg
Andrew Shin, William Regan, Rodrigo Gonzalez and Frank Pigula Meena Nathan, David Rimmer, Pedro J. del Nido, John E. Mayer, Emile A. Bacha,
Ventricular Septal Defect: Results of Primary Biventricular Repair in NeonatesAortic Atresia or Severe Left Ventricular Outflow Tract Obstruction with
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