145. Ventricular Septation for Double Inlet Ventricle – Avoiding Conduction Injury
Presented During: Congenital Rapid Fire Orals
Boston Children's Hospital
Boston, MA
United States - Contact Me
Dr. Feins is an Instructor in Surgery and congenital heart surgeon at Boston Children's Hospital. He attended Yale University for undergraduate studies, followed by Harvard Medical School. He completed his general surgery and cardiothoracic residency and fellowship training at the Massachusetts General Hospital, followed by congenital cardiovascular surgery fellowship training at Boston Children's Hospital. Dr. Feins' research focuses on pediatric cardiac surgery device development, including heart valve implants that can accommodate a child's growth, as well as novel tools/instruments for performing intraoperative EP mapping during complex congenital heart surgery.
Sunday, April 28, 2024: 11:15 AM - 11:22 AM
7 Minutes
Metro Toronto Convention Center
Room: Room 716
Description
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.
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
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.
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
Presentation Duration
You will have a 4 minute presentation followed by 3 minutes of discussion from the audience. All presenters must adhere to the presentation and discussion times provided. The AATS will begin to play music once your speaking time is exceeded.