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The hybrid procedure for the borderline left ventricle
Christopher K Davis1, Peter Pastuszko, John Lamberti
1Division of Cardiology, University of California, San Diego, California, USA.
Insights
The hybrid procedure offers a viable initial approach for infants with borderline left ventricles, potentially bridging to biventricular repair or single ventricle palliation. This strategy allows for more informed decisions as the child grows.
Area of Science:
- Pediatric Cardiology
- Congenital Heart Disease
- Surgical Innovation
Background:
- Left heart hypoplasia presents challenges in determining suitability for biventricular circulation.
- Historically, early and irreversible decisions between single ventricle or biventricular repair were necessary.
- Borderline left ventricles complicate surgical planning for congenital cardiac malformations.
Observation:
- Four patients with borderline left ventricles underwent assessment using echocardiograms and scoring systems.
- A left ventricular volume cutoff of 20 mL/m² was used to assess adequacy for biventricular repair.
- Pre-operative assessments yielded non-unanimous recommendations for repair type in all cases.
Findings:
- All four patients with borderline left ventricles were treated with the hybrid procedure.
- Post-hybrid procedure, two patients proceeded to single ventricle palliation and two to biventricular repair.
- The hybrid procedure facilitated survival in all patients, with a mean follow-up of 18 months.
Implications:
- The hybrid procedure may be the optimal initial strategy for neonates with borderline left ventricles.
- This approach acts as a bridge, enabling more definitive surgical decisions later in life.
- Delayed decision-making allows for better patient growth and more accurate assessment of cardiac structures.
Unlabelled:
IntroductionIn patients with varying degrees of left heart hypoplasia, it is often difficult to determine whether the left heart structures are adequate in size to support biventricular circulation. Historically, the decision to pursue a single ventricle or biventricular repair needed to be made early and was often irreversible. The hybrid procedure may be a better initial approach for patients with borderline left ventricles.
Methods:
We describe a series of four patients with various congenital cardiac malformations, all of whom had borderline left ventricles. Based on pre-operative echocardiograms, several scoring systems and left ventricle volumes were used to predict the optimal type of repair. A left ventricular volume of 20 millilitres per square metre was used as the minimum cut-off value for adequacy of biventricular repair.
Results:
The left ventricular volumes for the patients were 17.1, 23.7, 25.4, and 25.8 millilitres per square metre. In none of the four patients were the calculations unanimous in the recommendation to pursue either type of repair. All patients underwent the hybrid procedure and then eventual single ventricle palliation (two patients) or biventricular repair (two patients). All survived with a mean follow-up of 18 plus or minus 3.9 months.
Conclusions:
The hybrid procedure may be the best option in patients with a borderline left ventricle. It can serve as a bridge to a more definitive repair when patients are older, larger, and for whom the decision between single ventricle and biventricular repair can be more easily made.
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