Management of univentricular heart with systemic ventricular outflow obstruction by pulmonary artery banding and Damus-Kaye-Stansel operation.

BACKGROUND

Some patients with univentricular hearts who are candidates for Fontan operation may develop ventricular outflow tract obstruction after pulmonary artery banding (PAB) or Fontan. However, the indication for Damus-Kaye-Stansel (DKS) operation for these patients has not been clear. To clarify the indication, the changes in the diameter of ventricular outflow tract and the feasibility of DKS operation before or with Fontan were investigated.

METHODS

Among the patients with univentricular heart who underwent PAB, 21 patients had probable ventricular outflow obstruction with an aorta arising from the morphologic right ventricle. Diameter of ventricular outflow tract was measured before and after PAB, Glenn, and Fontan operations with or without DKS, and indexed by normal value (%VOT).

RESULTS

Six patients died after PAB. In the surviving 15 patients, %VOT decreased significantly from 103% (median, range 75%-153%) to 75% (range 52%-153%) after PAB. Four with very small %VOT (52% to 63%) after PAB needed DKS with bidirectional Glenn or central shunt operation, and 5 with moderately small %VOT (67% to 109%) after PAB needed DKS concomitantly with Fontan. A patient with %VOT of 117% before Fontan required DKS after Fontan. A patient with %VOT of 153% underwent Fontan without DKS and obstruction did not develop after Fontan. The remaining 4 patients were under consideration for Glenn or Fontan operation.

CONCLUSIONS

The diameter of the ventricular outflow tract decreased after PAB and Fontan operations. DKS operations might be indicated before Fontan if the indexed diameter of ventricular outflow tract after PAB was below 70% and concomitantly with Fontan if it was below 120%.