A Stepwise Approach To Intraoperative Assessment Of The Borderline Left Ventricle Constantine D. Mavroudis, MD, MSc, MTR, Sandhaya Ramlogan, MBBS, Jiyong Moon, MD, Davi F. Tenorio, MD, Charles D. Fraser, Jr, MD, E. Dean McKenzie, MD. Dell Children's Medical Center, Austin, TX, USA.
Introduction: Optimal neonatal surgical management of the borderline left ventricle remains incompletely defined, specifically regarding the decision to pursue single or biventricular circulation. Predictive scoring systems have been limited because of the inconsistent accuracy and correlation of various cardiac structural dimensions in predicting success or failure of biventricular circulation. As such, there remains utility in intraoperative evaluation to guide decision-making. Description: In this video we present our stepwise approach to the intraoperative assessment of the borderline left ventricle. The case is that of a 3.3kg male patient with a prenatal diagnosis of borderline left heart structures, consisting of moderately hypoplastic aortic valve (4.4mm, Z Score = -3.86), moderately hypoplastic mitral valve (7.16mm, Z Score = -3.25), non-apex forming left ventricle and a severely hypoplastic aortic arch (3.2mm, Z Score = -3.5). The patient was taken to the OR on day of life 6 for a Stage 1 Norwood versus an aortic arch advancement. A pre-bypass left atrial line was placed and demonstrated a left atrial pressure of 8mmHg. Upon test snaring of the ductus, this pressure did not increase significantly. The mitral valve accepted an 8mm dilator (Z score = 2.4), and direct assessment of the left ventricle did not demonstrate significant endocardial fibroelastosis. Given these data, the patient underwent an aortic arch advancement. The post-repair TEE was favorable, the patient recovered well from surgery, and was discharged on postoperative day 16. Conclusion: This stepwise approach can be used to guide intraoperative decision-making in these challenging patients.
