Ventricular Septation for Double Inlet Ventricle – Avoiding Conduction Injury
Presented During:
Sunday, April 28, 2024: 11:15AM - 11:22AM
Metro Toronto Convention Center
Posted Room Name:
Room 716
Abstract No:
145
Submission Type:
Abstract Submission
Authors:
Eric Feins (1), Ajami Gikandi (1), Jocelyn Davee (1), Edward O'Leary (1), Elizabeth DeWitt (1), Sunil Ghelani (1), Rebecca Beroukhim (1), Pedro del Nido (1), Sitaram Emani (1)
Institutions:
(1) Boston Children's Hospital, Boston, MA
Submitting Author:
Eric Feins
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Boston Children's Hospital
Boston Children's Hospital
Co-Author(s):
Ajami Gikandi
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Boston Children's Hospital
Boston Children's Hospital
Jocelyn Davee
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Boston Children's Hospital
Boston Children's Hospital
Edward O'Leary
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Boston Children's Hospital
Boston Children's Hospital
Elizabeth DeWitt
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Boston Children's Hospital
Boston Children's Hospital
Sunil Ghelani
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Boston Children's Hospital
Boston Children's Hospital
Rebecca Beroukhim
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Boston Children's Hospital
Boston Children's Hospital
*Pedro del Nido
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Boston Children's Hospital
Boston Children's Hospital
*Sitaram Emani
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Boston Children's Hospital
Boston Children's Hospital
Presenting Author:
Ajami Gikandi
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Abstract:
Objective: Ventricular septation is an alternative to Fontan in patients with double inlet left or right ventricle (DIV) but carries risk of complete heart block (CHB). This study describes our experience with ventricular septation and intraoperative conduction mapping.
Methods: Patients with DIV undergoing ventricular septation from 2017-2023 were identified. Conduction mapping was performed on the open, decompressed, beating heart to identify the His bundle (HB). Outcomes analyzed were CHB frequency, transplant-free survival, and freedom from reintervention.
Results: Ventricular septation was performed in 31 patients (25 DILV, 6 DIRV). Staged ventricular septation was performed in 27 patients. Seven progressed to complete septation and 1 underwent Fontan. Single-stage complete septation was performed in 4 patients. Twenty-five (83%) underwent conduction mapping during septation. Median mapping time was 7 minutes (range 1-18). Among 19 mapped DILV patients, the HB was localized to the region between the atrioventricular (AV) valves in 7 patients (4 superior, 2 inferior, 1 mid-inlet) and along the bulboventricular foramen (BVF) in 12 patients (7 anterior-superior margin, 5 anterior-inferior margin). All 5 mapped DIRV patients had conduction localized between the AV valves (3 inferior, 2 mid-inlet). Four patients required a permanent pacemaker (PPM) for CHB. One of these patients had transient CHB during preoperative cardiac catheterization and at surgery during heart retraction before mapping. Another patient had eventual recovery of AV conduction after PPM implantation. At a median follow-up of 14.5 months (IQR 1.4 months – 2.9 years) no deaths or transplants occurred. Late reoperations included resynchronization PPM implantation due to ventricular dyssynchrony (n=1), mitral valvuloplasty (n=3), and resection of subpulmonary outflow tract obstruction (n=2). Latest median oxygen saturation was 95% (IQR 93-98%). In DILV patients, L-looping (OR 7.7, 95% CI 1.6-51.2, P = 0.035) and L-malposed great vessels (OR 7.5, 95% CI 1.4-40.2, P = 0.019) were associated with conduction near the BVF on univariate regression analysis.
Conclusions: Ventricular septation can be performed safely in a subset of DIV patients. Conduction location can vary depending upon underlying anatomy. Intraoperative conduction mapping is a valuable adjunct that can guide surgical technique, including VSD patch positioning and suture placement, in order to avoid conduction injury.
Methods: Patients with DIV undergoing ventricular septation from 2017-2023 were identified. Conduction mapping was performed on the open, decompressed, beating heart to identify the His bundle (HB). Outcomes analyzed were CHB frequency, transplant-free survival, and freedom from reintervention.
Results: Ventricular septation was performed in 31 patients (25 DILV, 6 DIRV). Staged ventricular septation was performed in 27 patients. Seven progressed to complete septation and 1 underwent Fontan. Single-stage complete septation was performed in 4 patients. Twenty-five (83%) underwent conduction mapping during septation. Median mapping time was 7 minutes (range 1-18). Among 19 mapped DILV patients, the HB was localized to the region between the atrioventricular (AV) valves in 7 patients (4 superior, 2 inferior, 1 mid-inlet) and along the bulboventricular foramen (BVF) in 12 patients (7 anterior-superior margin, 5 anterior-inferior margin). All 5 mapped DIRV patients had conduction localized between the AV valves (3 inferior, 2 mid-inlet). Four patients required a permanent pacemaker (PPM) for CHB. One of these patients had transient CHB during preoperative cardiac catheterization and at surgery during heart retraction before mapping. Another patient had eventual recovery of AV conduction after PPM implantation. At a median follow-up of 14.5 months (IQR 1.4 months – 2.9 years) no deaths or transplants occurred. Late reoperations included resynchronization PPM implantation due to ventricular dyssynchrony (n=1), mitral valvuloplasty (n=3), and resection of subpulmonary outflow tract obstruction (n=2). Latest median oxygen saturation was 95% (IQR 93-98%). In DILV patients, L-looping (OR 7.7, 95% CI 1.6-51.2, P = 0.035) and L-malposed great vessels (OR 7.5, 95% CI 1.4-40.2, P = 0.019) were associated with conduction near the BVF on univariate regression analysis.
Conclusions: Ventricular septation can be performed safely in a subset of DIV patients. Conduction location can vary depending upon underlying anatomy. Intraoperative conduction mapping is a valuable adjunct that can guide surgical technique, including VSD patch positioning and suture placement, in order to avoid conduction injury.
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