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J Thorac Cardiovasc Surg 2009;137:371-379
© 2009 The American Association for Thoracic Surgery

Congenital Heart Disease

Biventricular repair in patients with heterotaxy syndrome

^a Department of Cardiac Surgery, Children's Hospital of Boston, Harvard Medical School, Boston, Mass
^b Department of Cardiology, Children's Hospital of Boston, Harvard Medical School, Boston, Mass

Received for publication May 16, 2008; revisions received October 1, 2008; accepted for publication October 26, 2008.

^_* Address for reprints: Frank A. Pigula, MD, Children's Hospital of Boston, Department of Cardiothoracic Surgery, 300 Longwood Ave, Farley 144, Boston, MA 02115. (Email: Frank.pigula{at}tch.harvard.edu).

Objective: Complex intracardiac and extracardiac anatomy is often confronted during biventricular repair in patients with heterotaxy syndrome. We examined factors affecting surgical outcomes in these patients.

Methods: Between January 1990 and July 2007, 371 patients received a diagnosis of heterotaxy syndrome; 91 (91/371, 24.5%) underwent biventricular repair. Left atrial isomerism was present in 73% (66/91) and right atrial isomerism in 10% (9/91), with indeterminate atrial anatomy in 17% (16/91). Median age at biventricular repair was 6.8 months (5 days to 22.3 years). Systemic venous anomalies were present in 75 patients, pulmonary venous anomalies in 26, and endocardial cushion defects in 36. Transposition complexes were present in 15 patients with atrioventricular discordance in 10; 8 underwent double switch, 2 received a physiologic repair, 2 underwent arterial switch, and 3 underwent the Rastelli operation. Other conotruncal anomalies included double-outlet right ventricle in 10 patients, tetralogy of Fallot in 3, and hemitruncus in 2. Separation of systemic from pulmonary venous return included intra-atrial baffling in 48 patients and extracardiac grafting in 2. Combined lesions were common, occurring in 99% (90/91). Statistical analysis with Kaplan–Meier and Cox proportional hazards models were performed.

Results: Average follow-up was 44.9 ± 57.5 months (3 days to 189.3 months). Kaplan–Meier estimated survival was 93.4% at 10 years; unbalanced complete atrioventricular canal was the only risk factor for mortality (P = .006). Subsequent procedures were common with a 10-year freedom from reoperation or reintervention of 38% ± 7.5%. Arrhythmias occurred in 36 (39.6%) patients; bradyarrhythmia in 27 (29.7%) and tachyarrhythmia in 15 (16.5%). Freedom from any arrhythmia was 53.9% ± 6.7% at 10 years.

Conclusions: Excellent survival for patients with heterotaxy undergoing biventricular repair can be expected, even for multiple, complex lesions. Reintervention is common, and arrhythmia is a long-term concern. This experience shows that patients with heterotaxy syndrome and complex cardiac anatomy can be considered for biventricular repair. Patients with unbalanced complete atrioventricular canal are a high-risk group for which selection criteria are particularly important.