Subaortic obstruction in univentricular heart: results using the double barrel Damus-Kaye Stansel operation

We review our experience with relief of subaortic obstruction in univentricular hearts following pulmonary artery banding (PAB) with double barrel Damus-Kaye Stansel procedure (DKS) and subsequent staged palliation to Fontan. The purpose was to determine if PAB alters semilunar valve function after the double barrel DKS procedure and if this staged approach negatively influences the achievement of Fontan palliation.

From January 1990 to March 2006, 27 patients underwent PAB (mean 22 days, range 1-150 days; 3.4kg) and coarctation as corrected simultaneously in 18 (18/27) 66%. These 27 patients subsequently had PA debanding and double barrel DKS connection at a mean age of 10.2 months (range 0.3-58 months). Pulmonary flow was established with a bidirectional Glenn in 14 patients; modified Blalock in 6, Glenn with modified Blalock in 5 and completion Fontan in 2 patients.

There were six early deaths (22%) following DKS: four patients receiving DKS with systemic shunt and two receiving bidirectional Glenn and systemic shunt. Patients receiving DKS with bidirectional Glenn shunt had a significantly lower mortality than patients who had a DKS with systemic shunt alone or in combination with a Glenn (p<0.03). Single ventricle to aortic gradient was reduced from 27.5+/-18mmHg to 3.4+/-2mmHg following double barrel DKS procedure (p<0.001). Aortic and pulmonary insufficiency was trace to mild in all patients. Nineteen of 21 survivors (90%) have completed Fontan with no early and three late deaths. Two patients are completion Fontan candidates.

PAB (+/-coarctation repair) with interval double barrel DKS is effective palliation for univentricular heart and excessive pulmonary blood flow. PAB does not create significant pulmonary insufficiency and subsequent DKS effectively relieves single ventricle to aortic gradient. Optimal second stage pulmonary blood flow is usually established with a bidirectional Glenn. The need for a Blalock shunt or a Glenn plus a Blalock is associated with increased mortality.