Boston - American Association for Thoracic Surgery

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89 TH ANNUAL MEETING MAY 9–MAY 13, 2009BOSTON, MASSACHUSETTS24. Left Ventricular Rehabilitation Is Effective in MaintainingTwo-Ventricle Physiology in the Borderline Left HeartSitaram Emani, Emile A. Bacha, * Doff McElhinney, Gerald Marx, Wayne Tworetsky,Frank A. Pigula, * Pedro J. del Nido *Childrens Hospital Boston, Boston, MA, USAInvited Discussant: Frank L. HanleyOBJECTIVE: In borderline left heart (BLH) disease, there is generally somedegree of endocardial fibroelastosis (EFE), mitral valve dysfunction, and/or aorticstenosis. The multilevel obstruction and impaired left ventricular (LV) systolic anddiastolic function place such patients at high risk for biventricular repair. We studiedthe effects of EFE resection with mitral and/or aortic valvuloplasty on LV diastolicand systolic function.METHODS: All patients with BLH structures and EFE who underwent an LVrehabilitation procedure (LV rehab) consisting of EFE resection and mitral valverepair, with or without aortic valvuloplasty, were retrospectively analyzed to determineoperative mortality, reintervention rates, and hemodynamic status. Echocardiographicmeasures obtained pre- and post-operatively included ejection fraction, LVend diastolic volume (EDV), LV mass/volume ratio, and estimated right ventricular(RV) pressure. At cardiac catheterization, left atrial (LAp) and RV/LV pressureratios were obtained. Postoperative LAp was obtained from the LA line early afterLV rehab. Pre- and post-operative values were compared by paired t-test.RESULTS: Between 1999 and 2007, 9 patients with EFE and BLH structuresunderwent LV rehab at a median age of 5.6 months (range 1–38 months). Nonehad associated ventricular septal defects. Interventions prior to LV rehab includedcoarctation repair (4/9) and aortic valve balloon dilation either in utero (5/9) orpostnatally (7/9). LV rehab consisted of mitral valvuloplasty and EFE resection(9/9 patients), aortic valvuloplasty (4/9), and subaortic resection (2/9). There wasno operative mortality, and at a median follow up of 13 months (1 to 95 months),there was one death from non cardiac causes (motor vehicle collision). Twopatients required reoperations, one for mitral valve replacement, and another foraortic and mitral valve repairs. No patients required single ventricle palliation orheart transplantation. Table 1 summarizes average pre- and postoperative hemodynamicdata. Significant increase in EF and LVEDV were observed, whereas LAp,and RV/LV ratios decreased postoperatively.Table 1Preoperative PostoperativeEjection fraction (%) 36 ± 12 58 ± 10 P < 0.01LVEDV z score –0.17 ± 1.7 2.72 ± 1.8 P < 0.05Mass/Vol ratio z score 0.68 ± 1.15 0.10 ± 2.1LA pressure (mmHg) 27.5 + 6.3 11 + 2.4 P < 0.01RV/LV systolic pressure ratio 0.78 ± 0.36 0.32 ± 0.11 P < 0.05* AATS Member112
AMERICAN ASSOCIATION FOR THORACIC SURGERYCONCLUSION: In patients with BLH disease, LV rehab with surgical EFE resectionand mitral and aortic valvuloplasty results in improved LV systolic and diastolicperformance and decreased RV pressures. This approach may provide analternative to single ventricle management in this difficult patient group.MONDAYAfternoon113
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AATS FUTURE MEETINGSMay 1-5, 2010Me
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