Biventricular Repair in Interrupted Aortic Arch and Ventricular Septal Defect With a Small Left Ventricular Outflow Tract

Abstract

Patients and MethodsAfter obtaining institutional review board approval we retrospectively identified 138 patients at our institution

Aortic Atresia or Complex Left Outflow Tract Obstruction in the Presence of a Ventricular Septal Defect

“…Some authors have suggested that routine VSD enlargement will reduce the risk of subsequent LVOTO but most studies have not felt that routine enlargement is necessary. 11 The rate of VSD enlargement with Yasui is generally low at 0% to 20% in most series 7 – 10 , 13 , 15 , 17 but this is very variable and much of this is based on subjective surgical assessment at the time of surgery—guidance being that if the septal defect is smaller than the pulmonary valve, then preference is to enlarge it.…”

“…However, this exposes the patients to an interstage period with cyanotic circulation and concomitant risks. 16 , 17 Despite these theoretical advantages of a staged approach, there is no conclusive evidence that primary repairs have a higher number of LVOT re-interventions 22 or that postoperative heart block and subsequent permanent pacemaker placement occurs more in the primary group.…”

“…However, in the group of patients with LVOTO and VSD then either a Ross-Konno or Yasui could be employed, so long as the VSD position and size are suitable for committing to the pulmonary artery. There are very few studies that have attempted to compare the outcomes of these 2 approaches 11 , 12 , 17 and none are able to identify specific morphological factors that might favor one over the other. The CHSS cohort 12 of patients with critical LVOTO attempted to review these approaches but the 2 groups were not strictly comparable as most of the Ross patients did not have a VSD (and so Yasui could never have been an option), most had undergone previous aortic valve interventions, and many (40%) had associated mitral valve disease.…”

“…Two other studies 11 , 17 have attempted comparisons, both with high early mortality in the neonatal Ross-Konno group (15-19% 11 , 17 ) and a higher number of early complications—although freedom from reoperation for both the LVOT and RV-PA conduit change was similar in both groups. 11 , 17 There is some evidence that the RV-PA conduit performs better in the Ross group than the Yasui, but the total re-intervention rates are similar in both groups. They conclude that although both options are reasonable, the Yasui is the preferred technique so long as the VSD is suitable for committing to the pulmonary valve.…”

Conversion of Norwood-Rastelli Procedure to “Anatomic” Biventricular Circulation With Takedown of Aortopulmonary Amalgamation After Aortic Valve Growth

“…Preoperative CT confirmed the degree of aortic valve hypoplasia with a diameter of 4.2 mm. For our surgical strategy (Figure 1), we performed the Norwood procedure (aortopulmonary amalgamation and arch reconstruction) without exogenous materials 2 and used a Sano shunt (6-mm e-PTFE conduit) for pulmonary blood flow. The atrial septal defect (ASD) was left open.…”