Simultaneous Systemic to Pulmonary Shunt and Pulmonary Artery Banding is a Viable Option for Neonatal Palliation of Single Ventricle Physiology.

BACKGROUND: A subset of neonates with single ventricle (SV) physiology has antegrade pulmonary blood flow that is deemed unlikely to be reliable until Glenn. We have used systemic to pulmonary shunt (SPS) with pulmonary artery banding (PAB) to optimize pulmonary blood flow while maintaining reserve antegrade flow. We hypothesize that this is an effective strategy that can be accomplished without the routine need for cardiopulmonary bypass (CPB).

METHODS: We retrospectively reviewed the records of 60 neonates who underwent combined SPS+PAB between 2004-2015. Data is presented as median with quartiles.

RESULTS: Children were 8 (4-19) days old at surgery and included 38 (63%) boys. Atresia or severe stenosis of the sub-pulmonary atrioventricular (AV) valve associated with pulmonary blood flow across a bulbo-ventricular foramen (BVF) was present in 37(62%). In 20 (33%), heterotaxy-associated unbalanced AV canal with pulmonary stenosis with or without anomalous pulmonary venous drainage was present. First stage palliation was accomplished without CPB in 44 patients (73%). There were seven (12%) hospital deaths, four amongst the 20 (20%) with heterotaxy. 53 children were followed for a median 5.1 (1.8 - 8.2) years. Three early re-interventions were required after initial palliation (one PAB adjustment, two SPS balloon angioplasties). Five additional heterotaxy patients experienced late mortality during follow-up. There were no early or emergent Glenn. 39 patients have reached Fontan circulation with a median pre-Fontan PA pressure of 14 (12-18) mmHg. One patient converted to bi-ventricular physiology and the remaining await completion Fontan. Heterotaxy was the only independent predictor of mortality (hazard ratio 10 (2.3-44, p<0.001)).

CONCLUSION: In SV patients with unreliable antegrade PA flow, SPS+PAB is an effective first stage palliation. SV patients with heterotaxy are at increased risk for mortality.