SHA24/064002

COMPLEX LEFT VENTRICULAR OUTFLOW OBSTRUCTION

SURGICAL APPROACHES MICHEL N. ILBAWI, M.D.

The Heart Institute for Children Advocate Children’s Hospital Chicago, Illinois

COMPLEX LEFT VENTRICULAR OUTFLOW OBSTRUCTION THE QUEST FOR BIVENTRICULAR REPAIR The common medical and surgical perception is that every attempt should be made to achieve biventricular repair because it has better short and long term outcome.

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COMPLEX LEFT VENTRICULAR OUTFLOW OBSTRUCTION THE QUEST FOR BIVENTRICULAR REPAIR Inappropriate pursuit of biventricular repair for critical LVOT patients with hypoplasia or dysfunction of the left side can result in poorer outcome than the pursuit of univentricular repair.

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COMPLEX LEFT VENTRICULAR OUTFLOW OBSTRUCTION THE QUEST FOR BIVENTRICULAR REPAIR Most patients with complex LVOT obstruction have borderline left ventricle with associated abnormal structural and functional features.

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COMPLEX LEFT VENTRICULAR OUTFLOW OBSTRUCTION MANAGEMENT PRINCIPLES • Insure anatomically and functionally adequate left ventricle and left sides structures.

• Choose the appropriate procedure to relieve obstruction.

• Use the hybrid approach to time the procedure(s) needed.

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COMPLEX LVOT OBSTRUCTION How to Insure the Adequacy of Borderline Left Ventricular Structures?

CAN BE EXTREMELY DIFFICULT

COMPLEX LVOT OBSTRUCTION The Criteria for Adequate Left Ventricle Many are available but none is reliable

COMPLEX LVOT OBSTRUCTION CRITERIA FOR ANATOMICALLY ADEQUATE HEART Mitral Valve: – MV/TV diameter – Valve area Aortoventricular Junction: – Diameter at the valve – Diameter at the root and ascending aorta 3.5 cm/m2

COMPLEX LVOT OBSTRUCTION CRITERIA FOR ANATOMICALLY ADEQUATE HEART Left Ventricle: •Inflow dimensions •Cross sectional area •Apex to base ratio •Spongy myocardium •Presence of fibroelastosis •Left ventricular volume – EDV < 110 ml/m2 – EF < 60% normal

COMPLEX LVOT OBSTRUCTION CRITERIA FOR FUNCTIONALLY ADEQUATE HEART Left Ventricle: – Ejection fraction < 40% – End diastolic pressure > 20 torr.

– Mean PA pressure > 50 torr.

– Under filled or “squashed” LV

Shunts: – Direction of flow in arch – Direction of shunt in PDA – Direction of shunt at ASD

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COMPLEX LVOT OBSTRUCTION SURGICAL OPTIONS • • • • •

Transcatheter balloon valvotomy Surgical valvuloplasty Modified Konno procedure Use of homograft root replacement Use of auto graft

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COMPLEX LVOT OBSTRUCTION SURGICAL OPTIONS • • • •

Norwood-Rastelli (Yasui) Single ventricle palliation Cardiac transplantation Hybrid procedure

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COMPLEX LVOT OBSTRUCTION AND BORDERLINE LEFT VENTRICLE “It is our choices, Harry, that show what we truly are, far more than our abilities.”

J.K. Rowling

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COMPLEX LVOT OBSTRUCTION SURGICAL OPTIONS SURGICAL AORTIC VALVULOPLASTY

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ZONE II BICUSPID STENOSTIC/REGURGITANT LEAFLETS Complete relief of leaflet fusion.

Extended commissuratory.

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COMPLEX LVOT OBSTRUCTION SURGICAL OPTIONS MODIFIED KONNO PROCEDURE WITH OR WITHOUT AORTIC VALVULOPLASTY

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COMPLEX LVOT OBSTRUCTION SURGICAL OPTIONS ROSS-KONNO PROCEDURE 1.With or without mitral valve surgery.

2.With or without resection of fibroelastosis.

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COMPLEX LVOT OBSTRUCTION SURGICAL OPTIONS RESULTS OF ROSS-KONNO PROCEDURE

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Operative features at the time of Ross operation in children with critical LVOTO (N = 39).

Patient-specific features associated with increased risk of timerelated death (N = 39, 12 deaths).

Survival after Ross operation (N = 39).

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ROSS KONNO RESULTS 14 PTS.

AGE (MOS.)

6.8 + 3.1

HOSPITAL MORTALITY

0/14

FOLLOW-UP (MOS.)

16.1 + 11.0

CONDUIT CHANGE

3/14

AORTIC REGURGITATION

0/14

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Univariate parametric model depicting survival stratified by age groups at time of the Ross procedure.

COMPLEX LVOT OBSTRUCTION SURGICAL OPTIONS NORWOOD/RASTELLI (YASUI)

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IS UNIVENTRICULAR APPROACH BETTER?

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IS UNIVENTRICULAR APPROACH BETTER?

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COMPLEX LVOT OBSTRUCTION AN ALTERNATIVE SURGICAL OPTION COULD THE HYBRID APPROACH BE THE ANSWER? •Associated anatomical problems MV, arch hypoplasia, small LV, EFE or AR, MR. •Associated myocardial dysfunction.

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COMPLEX LVOT OBSTRUCTION TECHNIQUES OF THE HYBRID APPROACH • • • •

Bilateral pulmonary artery band.

Stenting of ductus arteriosus.

Small-moderate atrial septal defect.

Resection of endocardial fibroelastosis.

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COMPLEX LVOT OBSTRUCTION USEFUL TECHNICAL TIPS • The use of main pulmonary artery to aorta shunt (reversed shunt) for occluded PDA. • Add an aortopulmonary shunt to increase pulmonary venous return and test the left side.

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COMPLEX LVOT OBSTRUCTION BORDERLINE LV CASE STUDY Newborn (3.1 Kg.) with ductal dependent hypoplasia of the left side.

– LV Dimensions – MV Dimensions – Aortic Valve

z = -2 z = -2 z = -3 THE HEART INSTITUTE FOR CHILDREN

CASE STUDY ECHO

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COMPLEX LVOT OBSTRUCTION BORDERLINE LV HYBRID PROCEDURE She underwent hybrid procedure at 6 days of age, ASD was not enlarged. Four months later the ASD started to close and completely closed at 8 months. S-P shunt was performed to ensure adequacy of left side.

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• • • •

Reconstruction of PA Closure of ASD Homograft root replacement Aortic arch reconstruction

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COMPLEX LVOT OBSTRUCTION BORDERLINE LV CASE REPORT • • • •

1.7 kg newborn with critical aortic stenosis Aortic annulus ---- Z = -3 MV & LV Z value low normal Patient was ballooned

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COMPLEX LVOT OBSTRUCTION BORDERLINE LV CASE REPORT • Patient continued to be in failure • PA suprasystemic • PDA closed

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COMPLEX LVOT OBSTRUCTION BORDERLINE LV CONVERSION TO HYBRID • PA – Aorta shunt (absent PDA) • ASD enlargement • Bilateral banding Currently 3.0 kg. waiting for Norwood Procedure THE HEART INSTITUTE FOR CHILDREN

COMPLEX LVOT OBSTRUCTION ADVANTAGES OF HYBRID APPROACH • Avoids early complex surgery.

• Allows time for the left side to “prove” itself.

• Provides time for recovery of left ventricular function.

• Simplifies subsequent complex biventricular repair.

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COMPLEX LVOT OBSTRUCTION CONCLUSIONS • There are several surgical options for the management of complex LVOT obstruction.

• The results are good and are improving.

• The adequacy of the left ventricular structures can adversely effect the outcome of surgery.

• Hybrid operation is useful in selected cases and may contribute to improved outcome in this group of difficult patients.THE HEART INSTITUTE FOR CHILDREN