The Borderline Neonatal LV: How to Approach It?

Objectives: Assessing the adequacy of a small left ventricle (LV) to support the systemic circulation remains problematic, despite the development of several echocardiographic and morphologic scores.

Methods: Twelve consecutive neonates (weight: 2.2–3.1 kg) with borderline LV underwent transcatheter or surgical, or combined palliation. Procedures included balloon aortic valvuloplasty (BAV) and arch stenting (n = 3), fetal BAV followed by a neonatal Ross (n = 1), a Giessen procedure (n = 2), and a primary Norwood type univentricular palliation (n = 6).

Result: Of 3 patients with initial transcatheter palliation, 2 have continued to do well with biventricular status (including staged removal of the arch stent and surgical repair of the arch), while one infant developed pulmonary hypertension (PA pressure at 80% of systemic, but surviving). The neonate with the Ross procedure could not be weaned from ECMO and parents refused the univentricular approach; cardiac catheterization 4 weeks postsurgery demonstrated an LVEDP of 23 mm Hg; the patient subsequently died. Both infants with a primary Giessen type palliation were converted to a Norwood type palliation at 4 and 6 weeks respectively, due to absence of LV growth. All 6 patients with primary univentricular palliation survived; 4 of them have proceeded to second stage Glenn palliation and 2 are awaiting surgery. In two of these six patients, preoperative cardiac catheterization demonstrated LVEDP of 18 and 20 mm Hg respectively, which enabled the choice of single ventricle palliation.

Conclusion: Choosing appropriate candidates for biventricular repair is challenging. In doubt, invasive preoperative measurement of LVEDP might help in choosing the type of initial palliation. Further studies will help determine critical LVEDP values.

Publication History

Article published online:
19 February 2021