This study reviews our early experience with the “reverse” double switch operation (R-DSO) for borderline left hearts. A retrospective review of children with borderline left hearts who underwent R-DSO between 2017 and 2021 was conducted. Patient characteristics and early hemodynamic and clinical outcomes were collected. R-DSO was performed in 8 patients with no operative or postoperative deaths; 5 underwent decompressing bidirectional Glenn. Left ventricular (LV) poor-compliance was the dominant pathophysiology. Four patients had undergone staged LV recruitment but were not candidates for anatomical biventricular circulation due to LV hypoplasia and/or diastolic dysfunction. 7/8 patients had risk factors for Fontan circulation including pulmonary vein stenosis, pulmonary hypertension, and pulmonary artery stenosis. Median age at R-DSO was 3.7 years (19 months-12 years). All patients were in sinus rhythm at discharge. At median follow-up of 15 months (57 days-4.1 years) no mortalities, reoperations or heart transplants had occurred. All patients had normal morphologic LV systolic function. In one patient, pre-existing pulmonary hypertension (HTN) resolved after R-DSO. Reinterventions included transcatheter mitral valve replacement for residual mitral stenosis and neo-pulmonary balloon valvuloplasty. In 4 patients follow-up catheterization done at a median of 519 days (320 days-4 years) demonstrated median cardiac index of 3.2 L/min/m2 (2.2-4); median sub-pulmonary left ventricular end diastolic pressure was 9 mm Hg (7-15); median inferior vena cava/baffle pressure was 8 mm Hg (7-13). R-DSO is an alternative to anatomical biventricular repair or single ventricle palliation in patients with borderline left hearts and can result in low inferior vena cava pressures and favorable early results. This approach can also relieve pulmonary HTN and allow future transplant candidacy.
Abbreviations:R-DSO (reverse double switch operation), LV (left ventricle), mLV (morphologic left ventricle), mRV (morphologic right ventricle), BDG (bidirectional Glenn), HLHS (hypoplastic left heart syndrome), MS (mitral stenosis), AS (aortic stenosis), DORV (double outlet right ventricle), TGA (transposition of the great arteries), LV-PA (left ventricle to pulmonary artery), iEDV (end diastolic volume index), EF (ejection fraction), EFE (endocardial fibroelastosis), CI (cardiac index), LVEDP (left ventricular end diastolic pressure), RVEDP (right ventricular end diastolic pressure), LVEDV (left ventricular end diastolic volume), SVC (superior vena cava), IVC (inferior vena cava), ASD (atrial septal defect), PVR (pulmonary vascular resistance), PLE (protein losing enteropathy), ccTGA (congenitally corrected transposition of the great arteries), LVOT (left ventricular outflow tract), NYHA (New York Heart Association)
To read this article in full you will need to make a payment
Purchase one-time access:Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
One-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:Subscribe to Seminars in Thoracic and Cardiovascular Surgery
Already a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
- Operations for improving left ventricular diastolic function.Curr Opin Cardiol. 2016; 31: 101-108
- Protein-losing enteropathy after the Fontan operation: An international multicenter study. PLE study group.J Thorac Cardiovasc Surg. 1998; 115: 1063-1073
- Demographic characteristics and estimated prevalence of Fontan-associated plastic bronchitis.Pediatr Cardiol. 2013; 34: 256-261
- Liver and cardiac function in the long term after Fontan operation.Ann Thorac Surg. 2008; 86: 177-182
- Hemodynamic parameters predict adverse outcomes following biventricular conversion with single-ventricle palliation takedown.J Thorac Cardiovasc Surg. 2017; 154: 572-582
- Combined atrial arterial switch operation (double switch) for hearts with Shone syndrome and pulmonary hypertension.J Thorac Cardiovasc Surg. 2006; 131: 471-473
- 1.5-Ventricle repair using left ventricle as the subpulmonary ventricle.Ann Thorac Surg. 2020; 110: e529-e530
- Biventricular converstion in unseptatable hearts: “Ventricular switch.Semin Thorac Cardiovasc Surg. 2021; 33: 172-180
- Biventricular strategies for neonatal critical aortic stenosis: High mortality associated with early reintervention.J Thorac Cardiovasc Surg. 2012; 144: 409-417
- Left ventricular recruitment in patients with hypoplastic left heart syndrome.Semin Thorac Cardiovasc Surg Pediatr Card Surg Ann. 2021; 24: 30-36
- Biventricular conversion in the borderline hypoplastic heart.Curr Cardiol Rep. 2020; 22: 115
- Risk factors for failed Fontan procedure after Stage 2 palliation.Ann Thorac Surg. 2021; 11: 610-618
- The relentless effects of the Fontan paradox.Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu. 2016; 19: 37-43
- Evaluation and management of the child and adult with Fontan circulation: A scientific statement from the.American Heart Association. Circulation. 2019; 140: e234-e284
- Long-term outcomes after first-onset arrhythmia in Fontan physiology.J Thorac Cardiovasc Surg. 2016; 152 (e1): 1355-1363
- Thrombotic and embolic complications associated with atrial arrhythmia after Fontan operation: Role of prophylactic therapy.J Am Coll Cardiol. 2016; 68: 1312-1319
- Ventricular pacing in single ventricles-A bad combination.Heart Rhythm. 2017; 14: 853-857
- Australia and New Zealand Fontan Registry. The extracardiac conduit Fontan procedure in Australia and New Zealand: Hypoplastic left heart syndrome predicts worse early and late outcomes.Eur J Cardiothorac Surg. 2014; 46: 465-473
- Fontan failure and death in contemporary Fontan circulation: Analysis from the last two decades.Ann Thorac Surg. 2018; 105: 1240-1247
- Predictors of survival in neonates with critical aortic stenosis.Circulation. 1991; 84: 2325-2335
- The infant with aortic arch hypoplasia and small left heart structures: Echocardiographic indices of mitral and aortic hypoplasia predicting successful biventricular repair.Pediatr Cardiol. 2017; 38: 1296-1304
- Predictors of outcome of biventricular repair in infants with multiple left heart obstructive lesions.Circulation. 2001; 104: 682-687
- Left ventricular remodeling and function in children with biventricular circulation after fetal aortic valvuloplasty.Pediatr Cardiol. 2015; 36: 1502-1509
- Congenitally corrected transposition of the great arteries: Anatomic, physiologic repair, and palliation.Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu. 2019; 22: 32-42
- Biventricular converstion after Fontan completion: A preliminary experience.J Thorac Cardiovasc Surg. 2022; 163: 1211-1223
- Early prophylactic pulmonary artery banding in isolated congenitally corrected transposition of the great arteries.Eur J Cardiothorac Surg. 2010; 38: 728-734
- Staged left ventricular recruitment after single-ventricle palliation in patients with borderline left heart hypoplasia.JACC. 2012; 60: 1966-1974
- Cardiac magnetic resonance versus routine cardiac catheterization before bidirectional Glenn anastomosis in infants with functional single ventricle. A prospective randomized trial.Circulation. 2007; 116: 2718-2725
Published online: September 27, 2022
Publication stageIn Press Journal Pre-Proof
Disclosures: SME is a consultant for Cheisi Pharmaceuticals.
Read at the AATS 102nd Annual Meeting, May 14-17, 2022, Boston, MA.
We have no related conflicts of interest. We have no external sources of funding to report.
IRB-P00037216, approved 10/29/20.
AATS Meeting Presentation.
© 2022 Elsevier Inc. All rights reserved.
ScienceDirectAccess this article on ScienceDirect
- Commentary: How far will we go?Seminars in Thoracic and Cardiovascular Surgery
- PreviewThe management of hypoplastic left heart syndrome (HLHS) has improved substantially over the past few decades; yet long-term outcomes are sub-optimal. Transplant-free survival at 6 years is around 60%.1 Complications of the Fontan circulation continue to plague late outcomes in this and other single ventricle patient populations.2 This has led to a renewed attempt to establish biventricular circulation3 or alternatively, identify transplant candidates early to improve overall outcomes. Prior studies indicate some success in recruiting the hypoplastic left ventricle (LV) for eventual incorporation as the systemic ventricle.