Damus-Kaye-Stanzel vs Bulboventricular Foramen resection

Transcription

1 Damus-Kaye-Stanzel vs Bulboventricular Foramen resection Emile Bacha, MD Director, Pediatric Cardiac Surgery Morgan Stanley Children s Hospital of New York-Presbyterian Columbia University Medical Center

2 Frame the problem Tricuspid atresia with d-tga DILV (S,L,L) Rare forms of single V, unrestricted pulmonary blood flow and subaortic systemic obstruction

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4 Lets agree on a few principles 1. Surgical strategy largely determined by: BVF Semilunar valves (aortic arch)

5 Lets agree on a few principles 1. Surgical strategy largely determined by: BVF Semilunar valves (aortic arch) 2. BVF resection is not applicable during neonatal period (exposure, friable tissue)

6 Lets agree on a few principles 1. Surgical strategy largely determined by: BVF Semilunar valves (aortic arch) 2. BVF resection is not applicable during neonatal period (exposure, friable tissue) Therefore, if subas (restrictive BVF) is severe enough to warrant resection, then DKS/Norwood is necessary (palliative switch?)

7 Lets agree on a few principles 1. Surgical strategy largely determined by: BVF Semilunar valves (aortic arch) 2. BVF resection is not applicable during neonatal period (exposure, friable tissue) Therefore, if subas (restrictive BVF) is severe enough to warrant resection, then DKS/Norwood is necessary (palliative switch?) 3. If there is aortic arch obstruction, Norwood

8 Does PA banding really increase the chances of restriction

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14 How do you determine if a BVF is restrictive, or will be restrictive?

15 a systemic outflow gradient at the subvalvular level

16 a systemic outflow gradient at the subvalvular level or a bulboventricular foramen/aortic valve diameter ratio of 1 or less

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18 You are more likely to end up with obstruction if the BVF is small to begin with

19 If the aortic arch is obstructed, the BVF is more likely to be small

20 Patients WITHOUT aortic arch obstruction: patients who developed BVF obstruction had sign. smaller BVF index area

21 Conclusions (Matitiau et al) Neonate with a BVF size index of < 2cm 2 /m 2 are at high risk for developing BVF obstruction

22 What happens to the BVF even if you DON T band the PA?

23 Modified Norwood Operation for Single Left Ventricle and Ventriculoarterial Discordance: An Improved Surgical Technique. Mosca, Bove et al Ann Thorac Surg 1997;64:

24 N=20: Although the absolute bulboventricular foramen size did increase in approximately 50% of patients, this was not predictable, and when indexed to body surface area, there was an overall decrease with time (20%)

25 Management strategies: DKS vs BVF resection (or other non arch procedures)

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30 BVF resection

31 BVF resection Usually in older patients who have been banded and started out with large BVFs

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36 BVF resection: location of the conduction system Anderson R. H. et al.; Ann Thorac Surg 1998;66:

37 Technique of DKS (Norwood) in setting of d-tga or l-tga

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41 Mosca et al, ATS 1997

42 Mosca et al, ATS 1997

43 Mosca et al, ATS 1997

44 Conclusion For patients with single ventricle, unrestrictive pulmonary blood flow and an aorta arising from an outflow chamber connected to the main ventricle via a BVF (usually DILV/SLL or Tricuspid Atresia/d-TGA)

45 Conclusions BVF size in the neonate is an important predictor of late obstruction Neonate with a BVF size index of < 2cm 2 /m 2 are at high risk for developing BVF obstruction Although the BVF appears to grow, its growth does not keep pace with somatic growth in most patients

46 Conclusion (management) If there is AS or aortic arch hypoplasia: Norwood

47 Conclusion (management) If there is AS or aortic arch hypoplasia: Norwood If there is any evidence of subas (restrictive If there is any evidence of subas (restrictive BVF): Norwood

48 Conclusion (management) If there is AS or aortic arch hypoplasia: Norwood If there is any evidence of subas (restrictive BVF): Norwood For patients with no AS/ao arch hypoplasia and large BVF, PAB may be an option (very rare!)