To Do a BiV or Single V Repair in Borderline Cases: That Is the Question
Are there effective strategies to achieve a biventricular repair (BVR) in borderline BVR candidates with a ventricular septal defect (VSD)?
Forty-two patients from a single institution in Japan between 1991 and 2012, deemed borderline BVR candidates (patients with large or multiple VSDs with poor septal formation, straddling atrioventricular [AV] valves with hypoplastic ventricles whose areas or volumes were 40-70% of published norms, double outlet right ventricles with remote VSDs) were palliated and followed with the intent to achieve BVR until it was deemed no longer possible.
The decision of whether to follow the BVR or single-ventricle pathway (single-ventricle repair [SVR]) was deferred beyond the neonatal period. Pulmonary artery banding or Blalock-Taussig shunt placement with relief of aortic arch obstruction, intracardiac interventions to increase transmitral blood flow (including relief of supramitral stenosis and atrial septal defect restriction), or a palliative arterial switch in patients with transposed hemodynamics, were performed as appropriate. Nineteen (50%) achieved BVR, seven crossed over to a SVR strategy, two underwent a 1.5 V repair, with 10 deaths, (three awaiting decisions) by a median age of 31 months.
This staged BVR-oriented strategy was more complex and took longer than a simple SVR strategy, but achieved a BVR in some patients who would otherwise have been SVRs.
This is an excellent paper that underscores the perplexing question many pediatric cardiologists and cardiovascular surgeons face. The pursuit of BVR in borderline cases is a clinical dilemma that has resulted in creative solutions. Categorizing which patients would benefit best from a BVR or SVR is not clear cut. With improvement in modern imaging modalities, quantification of ventricular volumes and more precise delineation of intracardiac anatomy, especially AV valve commitment, are now possible. While attempting a BVR is commendable, in some instances, persisting in this pathway may be deleterious to a future SVR crossover. Unfortunately, identifying the ‘point of no return,’ beyond which a crossover is no longer possible, is difficult to ascertain. Furthermore, is a ‘bad’ BVR really preferable to a ‘good’ SVR?
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