Invited Commentary

Abstract

The long-term outcome of single ventricle physiology remains pretty dismal without surgical interventions. The current management ultimately favors toward the path of the Fontan operation, and these patients could be managed with relatively good palliation. However, the management between the times of clinical diagnosis and the optimal achievement of the Fontan operation remains much more debatable. It is well documented that the second-stage bidirectional cavopulmonary shunt has optimized the preparation for the ultimate Fontan operation. The goal of the interim surgical therapy for single ventricle is to establish unobstructed systemic circulation and competent atrioventricular and semilunar valves that serve to preserve the systolic and diastolic ventricular function crucial for the Fontan physiology. Equally important is the avoidance of excessive pulmonary blood flow and obstructive vasculature that may compromise the long-term Fontan outcome. Although many alternative surgical procedures have been described, the two main contenders are the early Norwood or Damus-Kaye-Stansel procedure vs pulmonary artery banding (PAB), particularly in the presence of concomitant systemic obstruction, depending on the comfort and results of various procedures between different centers [1Tchervenkov C.I. Shum-Tim D. Béland M.J. Jutras L. Platt R. Single ventricle with systemic obstruction in early life: comparison of initial pulmonary artery banding versus the Norwood operation.Eur J Cardiothorac Surg. 2001; 19: 671-677Crossref PubMed Scopus (30) Google Scholar]. Traditional PAB has the advantage of avoiding a complex operation, cardiopulmonary bypass, and systemic-pulmonary shunt early during the neonatal period, but it has been related to increased reintervention and poor preparation for the Fontan candidate due to the presence of systemic obstruction, as suggested by the group 1 patients in this study [2Kajihara N. Asou T. Takeda Y. et al.Pulmonary artery banding for functionally single ventricles: impact of tighter banding in staged Fontan era.Ann Thorac Surg. 2010; 89: 174-180Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar]. This may arguably compromise the Fontan operation if not addressed aggressively. Over the decades, the experience of many pediatric centers and surgical intensive care teams has gained comfort and good results with neonatal and infant complex operations. Although some are more comfortable with the Norwood type of operation, others are more comfortable with neonatal PAB and bidirectional cavopulmonary shunt early in infancy. Kajihara and colleagues [2Kajihara N. Asou T. Takeda Y. et al.Pulmonary artery banding for functionally single ventricles: impact of tighter banding in staged Fontan era.Ann Thorac Surg. 2010; 89: 174-180Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar] demonstrated this point very well and were able to gain excellent results with the later approach. Subsequently, with better preservation of the requirement for the optimal Fontan as described, they demonstrated that their early aggressive tighter PAB strategy could prevent volume overload, and if followed with right heart bypass early enough, may prevent the occurrence of systemic obstruction. However, one caution with their article is that the two groups of patients were managed in two different eras of pediatric cardiac surgery and may not be extrapolated in other centers that do not have the same expertise and philosophic approach to the same cardiac anomalies. Pulmonary Artery Banding for Functionally Single Ventricles: Impact of Tighter Banding in Staged Fontan EraThe Annals of Thoracic SurgeryVol. 89Issue 1PreviewIn this study, we assessed our surgical strategy, tighter pulmonary artery banding (PAB) during the neonatal period, as an initial step followed by early application of bidirectional cavopulmonary shunts (BCPS) in infancy, to treat functionally single ventricles with unobstructed pulmonary blood flow. Full-Text PDF