Hypoplastic Left Heart Syndrome with Mitral Stenosis and Aortic Atresia—Echocardiographic Findings and Early Outcomes

Abstract

Mitral stenosis/aortic atresia (MS/AA) has been reported as a high-risk variant of hypoplastic left heart syndrome (HLHS), potentially related to ventriculocoronary connections (VCCs) or endocardial fibroelastosis (EFE) and myocardial hypoperfusion. We aimed to identify echocardiographic and clinical factors associated with early death or transplant in this group. Patients with HLHS MS/AA treated at our center between 2000 and 2020 were included. Pre-stage I palliation echocardiograms were reviewed. Certain imaging factors, such as determination of VCC, EFE, and measurement of tricuspid annular plane systolic excursion were measured from retrospective review of preoperative images; others were derived from clinical reports. Groups were compared according to primary outcome of death or transplant prior to stage II palliation. Of 141 patients included, 39 (27.7%) experienced a primary outcome. Ventriculocoronary connections were identified in 103 (73.0%) patients and EFE in 95 (67.4%) patients. Among imaging variables, smaller ascending aorta size (median, 2.2 [interquartile range (IQR) 1.7-2.8] vs 2.6 [2.2-3.4] mm, P=.01) was associated with primary outcome. There was similar frequency of VCC (74.4% vs 72.5%, P=.83), EFE (59.0% vs 72.5%, P=.19), moderate or greater tricuspid regurgitation (5.1% vs 5.9%, P=1.00), and similar right ventricular systolic function (indexed tricuspid annular plane systolic excursion 32.5±7.3 vs 31.4±7.2mm/m2, P=.47) in the primary outcome group compared to other patients. Clinical factors associated with primary outcome included lower birth weight (mean, 2.8±SD 0.8 vs 3.3±0.5kg, P=.0003), gestational age <37weeks (31.6% vs 4.9%, P<.0001), longer cardiopulmonary bypass time (median, 112 [IQR, 93-162] vs 82 [71-119] minutes, P=.001), longer intensive care unit length of stay (median, 19 [IQR, 10-30] vs 10 [7-15] days, P=.001), and extracorporeal membrane oxygenation following stage I palliation (43.6% vs 8.8%, P<.0001). Presence of VCCs and EFE was not associated with death or transplant after controlling for birth weight and era of stage I palliation. In one of the largest reported single-center cohorts of HLHS MS/AA, there were few pre-stage I palliation imaging characteristics associated with primary outcome. Imaging findings evaluated in this study, including the presence of VCC and/or EFE as determined using highly sensitive echocardiogram criteria, should not preclude intervention, although impact on long-term outcomes requires further evaluation.