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J Thorac Cardiovasc Surg 2006;132:1081-1086
© 2006 The American Association for Thoracic Surgery

Surgery for Congenital Heart Disease

Ductal stenting retrains the left ventricle in transposition of great arteries with intact ventricular septum

Kothandam Sivakumar, MD, DMa,*, Edwin Francis, MD, DMa, Prasad Krishnan, MS, MChb, Jagdish Shahani, MDb

a Department of Pediatric Cardiology, Apollo Hospital, Colombo, Srilanka
b Department of Cardiac Surgery, Apollo Hospital, Colombo, Srilanka.

Received for publication May 17, 2006; revisions received July 3, 2006; accepted for publication July 7, 2006.

* Address for reprints: K. Sivakumar, MD, DM, Consultant Pediatric Cardiologist, Apollo Hospital, Colombo-05, Srilanka (Email: drkumarsiva{at}hotmail.com).

OBJECTIVE: In late presenters with transposition of the great arteries, intact ventricular septum, and regressing left ventricle, left ventricular retraining by pulmonary artery banding and aortopulmonary shunt is characterized by a stormy postoperative course and high costs. Ductal stenting in the cardiac catheterization laboratory is conceptualized to retrain the left ventricle with less morbidity.

METHODS: Recanalization and transcatheter stenting of patent ductus arteriosus was performed in patients with transposition to induce pressure and volume overload to the regressing left ventricle. Serial echocardiographic monitoring of left ventricular shape, mass, free wall thickness, and volumes was done, and once the left ventricle was adequately prepared, an arterial switch was performed. The ductal stent was removed and the remaining surgical steps were similar to a 1-stage arterial switch operation. Postoperative course, need for inotropic agents, and left ventricular function were monitored.

RESULTS: Ductal stenting in 2 patients aged 3 months resulted in improvement of indexed left ventricular mass from 18.9 to 108.5 g/m2, left ventricular free wall thickness from 2.5 to 4.8 mm, and indexed left ventricular volumes from 7.6 to 29.5 mL/m2 within 3 weeks. Both patients underwent arterial switch (bypass times 125 and 158 minutes) uneventfully, needed inotropic agents and ventilatory support for 3 days, and were discharged in 8 and 10 days.

CONCLUSIONS: Ductal stenting is a less morbid method of left ventricular retraining in transposition of the great arteries with regressed left ventricle. Its major advantages lie in avoiding pulmonary artery distortion and neoaortic valve regurgitation resulting from banding and also in avoiding thoracotomy.

Abbreviations and Acronyms ASO = arterial switch operation; IVS = intact ventricular septum; LV = left ventricle (ventricular); PA = pulmonary artery; PDA = patent ductus arteriosus; RV = right ventricle (ventricular); TGA = transposition of the great arteries






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