The infant with single ventricle and excessive pulmonary blood flow: results of a strategy of pulmonary artery division and shunt.
BACKGROUND
The infant with a single ventricle and excessive pulmonary blood flow requires early protection of the pulmonary vascular bed to insure suitability for a subsequent Fontan procedure. The traditional approach, pulmonary artery banding, has had disappointing results. We have pursued an alternate strategy: division of the pulmonary artery, and placement of a systemic-to-pulmonary artery shunt. Potential sites of systemic outflow tract obstruction are simultaneously bypassed, by either a Damus-Kaye-Stansel, or modified Norwood procedure.


METHODS
From January 1996 to June 2001, 22 infants were treated by this strategy. Patients with hypoplastic left heart syndrome were excluded. Median age was 18 days (range 2 days to 6 months). In addition to pulmonary artery division and shunt, 3 of 22 patients underwent a Damus-Kaye-Stansel procedure, and 13 of 22 patients underwent a modified Norwood procedure.


RESULTS
There were no operative deaths, and one late death. Actuarial survival beyond 30 months was 90%. At follow-up catheterization in 22 patients, median transpulmonary gradient was 7 mmHg (range 4 to 18), and median pulmonary vascular resistance 1.9 Wood units (range 0.9 to 3.3). Twenty-one patients have undergone a subsequent bidirectional superior cavopulmonary connection, and 6 a Fontan procedure, with no deaths. No patient developed subaortic stenosis, or aortic arch obstruction. Neoaortic insufficiency was none or trivial in 12 patients, mild in 3, and moderate in 1.


CONCLUSIONS
In patients with a functional single ventricle and excessive pulmonary flow, a strategy of pulmonary artery division and shunt, along with prophylactic bypass of systemic outflow obstruction, carries low operative and midterm mortality. It provides consistent protection of the pulmonary vascular bed, avoids subaortic stenosis and aortic arch obstruction, minimizes neoaortic insufficiency, and ensures suitability for progression along a Fontan pathway. These results provide a comparison for alternate strategies, including pulmonary artery banding.
Bradley
Scott M
SM
Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston 29425, USA. bradlesm@musc.edu
Simsic
Janet M
JM
Atz
Andrew M
AM
Dorman
B Hugh
BH
D000206:Actuarial Analysis; D005260:Female; D006330:Heart Defects, Congenital / Q000401:mortality / Q000601:surgery*; D006352:Heart Ventricles / Q000002:abnormalities*; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008168:Lung / Q000098:blood supply*; D008297:Male; D011183:Postoperative Complications / Q000401:mortality; D011651:Pulmonary Artery / Q000601:surgery*; D011669:Pulmonary Wedge Pressure / Q000502:physiology; D012039:Regional Blood Flow / Q000502:physiology; D015996:Survival Rate; D014655:Vascular Resistance / Q000502:physiology