Hybrid approach as bridge to biventricular repair in a neonate with critical aortic stenosis and borderline left ventricle

Abstract

A newborn presented with severe aortic valve stenosis and a borderline hypoplastic left ventricle due to disproportionate left ventricular hypertrophy (maternal diabetes). The aortic valve was balloon dilated and the infant tolerated a biventricular circulation. However, severe retrograde pulmonary hypertension and mitral regurgitation developed, indicating that biventricular circulation was not possible at that stage. A hybrid approach with ductal stenting, atrial septostomy and bilateral dilatable pulmonary artery band placement was followed on day 25. This allowed the left ventricle several months to adapt to lower pressure and normoglycemic conditions. At re-evaluation after 8 months biventricular repair appeared possible: the ductus was closed with Amplatzer occluders and the pulmonary artery bands were opened up with bilateral balloon angioplasty of the dilatable bands. At the age of 3 years, the infant is doing well with a biventricular circulation and normal pulmonary artery pressure. The hybrid approach allowed adequate time (months) for careful consideration and acted as a bridge to biventricular repair in this infant.