Surgical approaches for CHD: and update on success and challenges

Congenital heart surgery is a constantly evolving specialty informed by experience and science. Recent trends confirm this with three key findings that challenge existing dogma and suggest new paths. These include: surgical aortic valve intervention vs. balloon valvotomy, shunt type in staged palliation for hypoplastic left heart syndrome (HLHS), and strategies for selective cerebral perfusion (SCP).

Early surgical aortic valve intervention vs. traditional balloon aortic valvuloplasty; shunt type in staged palliation for hypoplastic left heart syndrome; strategies for SCP.

We reviewed the current literature for congenital heart disease in the last year. We identified a number of surgical themes that suggest a move of the field in new directions. First is a re-examination of strategies for early intervention in critical aortic stenosis. Although balloon valvotomy has been the standard therapy for this disease over the last 20 years, data now suggest a potential role for primary surgery in this disease. Secondly, we examine new results for palliation of HLHS. The Pediatric Heart Network's (PHN) single ventricle reconstruction (SVR) trial compared shunt types. However, palliation for HLHS is a three-stage process and final judgment regarding the best strategy for stage I palliation should be reserved for an analysis of post-Fontan palliation. New data from the PHN are now beginning to show equipoise for the two palliative strategies. Third, we examine new studies that exemplify the complexities that underlie SCP strategies as an alternative to deep hypothermic circulatory arrest (DHCA). In all cases, sequential movement forward suggests that either continued or more rigorous prospective randomized studies be performed to unravel the complexities of treatment for congenital heart disease.