Bailout shunt/banding for backward left heart failure after adequate neonatal coarctectomy in borderline left hearts

Abstract

OBJECTIVES: To determine the outcome of a bailout procedure using the right ventricle to re-Assist the left ventricle in neonates after technically adequate coarctectomy but a failing borderline left heart. METHODS: The surgical procedure was performed on bypass. A 'reversed' 6-mm surgical shunt was inserted between the pulmonary trunk and the descending aorta together with bilateral branch pulmonary artery banding. RESULTS: Over a 10-year period, 89 neonates presented with coarctation and small left hearts. In 9 neonates, a hybrid procedure was performed at the outset. The remaining 80 underwent extended end-To-end coarctectomy. Two of these, despite adequate coarctectomy, developed retrograde cardiac failure with supra-systemic pulmonary hypertension, dilating right ventricles and progressive cardiogenic shock. The progressively dilating right ventricles inhibited left ventricular filling. Reversed surgical shunts were performed at 9 and 7 days post-coarctectomy. Both infants recovered rapidly and could be extubated after 4 and 7 days, respectively. Patient 1 proceeded to a univentricular repair and Patient 2 to a biventricular repair. CONCLUSIONS: Reversed surgical shunt with bilateral banding of the branch pulmonary arteries after neonatal coarctectomy can be successfully employed as a bailout procedure in cases where a borderline left heart with growth potential cannot tolerate a biventricular circulation. It may act as an acute life-saving measure as well as a bridge to later repair. If high risk for backward failure exists in a borderline left heart with catch-up growth potential, a primary hybrid procedure is probably a more elegant and predictable strategy.