Left ventricular hypoplasia: to septate or not?
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REVIEW ARTICLE
Left ventricular hypoplasia: to septate or not? Byalal Raghavendrarao Jagannath 1 Received: 22 November 2019 / Revised: 18 June 2020 / Accepted: 22 June 2020 # Indian Association of Cardiovascular-Thoracic Surgeons 2020
Abstract When do we label a left ventricle as small? How is the decision made regarding suitability for a two-ventricle repair? Are dimensions the only criteria with which we decide, whether a ventricle will support the systemic circulation? Can we actually stimulate the growth of a borderline small left ventricle, so that it could support the systemic circulation in future? What role does mass and shape have to play in whether a borderline ventricle will support a biventricular repair? What role does the morphology and segmental anatomy play in this decision-making? This is a review article to address these issues. Keywords Hypoplastic LV . Critical aortic stenosis . Unbalanced AV canal . Recruitment of LV . BV repair or SV repair . Strategies for SV or BV pathways
Introduction A small left ventricle (LV) is a commonly used term, when one is faced with the Hobson’s choice in a neonate, who presents with cyanosis, on prostaglandin infusion, and echo reveals a probable diagnosis of hypoplastic left heart syndrome (HLHS) or hypoplastic left heart complex (HLHC). To do a complex biventricular (BV) repair, with possibility of repeat interventions, and long-term outcomes that are yet to be evaluated, or do an equally complex palliative single ventricular (SV) repair, which has definite two more stages, has been shown to have a limited durability. To these, a third hybrid procedure can be added with its own attendant morbidity. Other groups of patients are with unbalanced atrioventricular canals, where the LV appears small due to the override straddle of the atrioventricular (AV) valve. With increasing technical expertise, supported by efficient postoperative management, more patients are being offered primary high-risk BV repair over SV palliation. The longterm poor outcomes with Fontan circulation with poor availability of organs for transplantation, in the event of Fontan failure, are the main driving forces for considering a highrisk BV repair over palliation. In India, additionally
* Byalal Raghavendrarao Jagannath [email protected] 1
Department of Pediatric Cardiac Surgery, Star Hospital, Banjara Hills, Hyderabad, India
prohibitive cost of transplantation, repeated investigation, and admission for Fontan failure are an added impetus for considering BV repair or even a staged BV repair. This is dependent on the adequacy of the LV to support the systemic circulation. The other driving impetus is the possible staging of interventions, to enable recruitment of a small LV. The focus has always been on the ventricular size, shape, and physical characteristics, ignoring the physiology, which often takes a back seat in these deliberations. The major anatomical substrates, where the LV plays a determining role, are HLHS, critical aortic stenosis, mitral stenosis/mitral valve abnormal
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