Oh Nicholas A, Doulamis Ilias P, Guariento Alvise, Piekarski Breanna, Marx Gerald R, Del Nido Pedro J, Emani Sitaram M
Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Mass.
Department of Cardiothoracic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio.
JTCVS Open. 2022 Dec 13;13:278-291. doi: 10.1016/j.xjon.2022.11.020. eCollection 2023 Mar.
Restoration of biventricular circulation is an alternative management strategy in unbalanced atrioventricular canal defects (uAVCDs), especially in patients with risk factors for single-ventricle palliation (SVP) failure. When ventricular volume is inadequate for biventricular circulation, recruitment procedures may accommodate its growth. In this study, we review our uAVCD experience with biventricular conversion (BIVC) after prior SVP.
This is a single-institution, retrospective cohort study of uAVCD patients who underwent BIVC after SVP, with staged recruitment (staged) or primary BIVC (direct) between 2003 to 2018. Mortality, unplanned reinterventions, imaging, and catheterization data were analyzed.
Sixty-five patients underwent BIVC from SVP (17 stage 1, 42 bidirectional Glenn, and 6 Fontan). Decision for conversion was based on poor SVP candidacy (n = 43) or 2 adequately sized ventricles (n = 22). Of the 65 patients, 20 patients underwent recruitment before conversion. The staged group had more severe ventricular hypoplasia than the direct group, reflected in prestaging end-diastolic volume scores (-4.0 vs -2.6; < .01), which significantly improved after recruitment (-4.0 to -1.8; < .01). Median follow-up time was 1.0 years. Survival and recatheterizations were similar between both groups (hazard ratio, 0.9; 95% CI, 0.2-3.7; = .95 and hazard ratio, 1.9; 95% CI, 0.9-4.1; = .09), but more reoperations occurred with staged approach (hazard ratio, 3.1; 95% CI, 1.3-7.1; = .01).
Biventricular conversion from SVP is an alternative strategy to manage uAVCD, particularly when risk factors for SVP failure are present. Severe forms of uAVCDs can be converted with staged BIVC with acceptable mortality, albeit increased reinterventions, when primary BIVC is not possible.
恢复双心室循环是治疗不平衡型房室通道缺损（uAVCD）的一种替代管理策略，尤其适用于存在单心室姑息治疗（SVP）失败风险因素的患者。当心室容积不足以支持双心室循环时，可采用扩容程序促进其生长。在本研究中，我们回顾了我们在先前行SVP后进行双心室转换（BIVC）治疗uAVCD的经验。
这是一项单机构回顾性队列研究，研究对象为2003年至2018年间接受SVP后BIVC治疗的uAVCD患者，包括分期扩容（分期）或一期BIVC（直接）。分析了死亡率、非计划性再次干预、影像学和心导管检查数据。
65例患者从SVP转换为BIVC（17例为一期，42例为双向格林手术，6例为Fontan手术）。转换的决定基于SVP候选情况不佳（n = 43）或两个心室大小合适（n = 22）。65例患者中，20例在转换前进行了扩容。分期组的心室发育不全比直接组更严重，这反映在分期前舒张末期容积评分上（-4.0对-2.6；P <.01），扩容后显著改善（-4.0至-1.8；P <.01）。中位随访时间为1.0年。两组的生存率和再次心导管检查情况相似（风险比，0.9；95%置信区间，0.2 - 3.7；P =.95和风险比，1.9；95%置信区间，0.9 - 4.1；P =.09），但分期方法的再次手术更多（风险比，3.1；95%置信区间，1.3 - 7.1；P =.01）。
从SVP转换为双心室是治疗uAVCD的一种替代策略，尤其是在存在SVP失败风险因素时。对于严重形式的uAVCD，当无法进行一期BIVC时，分期BIVC可实现转换，死亡率可接受，尽管再次干预有所增加。
