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The Infant with Aortic Arch Hypoplasia and Small Left Heart Structures: Echocardiographic Indices of Mitral and Aortic Hypoplasia Predicting Successful Biventricular Repair

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Abstract

In infants with aortic arch hypoplasia and small left-sided cardiac structures, successful biventricular repair is dependent on the adequacy of the left-sided structures. Defining accurate thresholds of echocardiographic indices predictive of successful biventricular repair is paramount to achieving optimal outcomes. We sought to identify pre-operative echocardiographic indices of left heart size that predict intervention-free survival in infants with small left heart structures undergoing primary aortic arch repair to establish biventricular circulation (BVC). Infants ≤2 months undergoing aortic arch repair from 1999 to 2010 with aortic and/or mitral valve hypoplasia, (Z-score ≤−2) were included. Pre-operative and follow-up echocardiograms were reviewed. Primary outcome was successful biventricular circulation (BVC), defined as freedom from death, transplant, or single ventricular conversion at 1 year. Need for catheter based or surgical re-intervention (RI), valve annular growth, and significant late aortic or mitral valve obstruction were additional outcomes. Fifty one of 73 subjects (79%) had successful BVC and were free of RI at 1 year. Seven subjects failed BVC; four of those died. The overall 1 year survival for the cohort was 95%. Fifteen subjects underwent a RI but maintained BVC. In univariate analysis, larger transverse aorta (p = 0.006) and aortic valve (p = 0.02) predicted successful BVC without RI. In CART analysis, the combination of mitral valve (MV) to tricuspid valve (TV) ratio ≤0.66 with an aortic valve (AV) annulus Z-score ≤−3 had the greatest power to predict BVC failure (sensitivity 71%, specificity 94%). In those with successful BVC, the combination of both AV and MV Z-score ≤−2.5 increased the odds of RI (OR 3.8; CI 1.3–11.4). Follow-up of non-RI subjects revealed improvement in AV and MV Z-score (median AV annulus changed over time from −2.34 to 0.04 (p < 0.001) and MV changed from −2.88 to −1.41 (p < 0.001), but residual mitral valve stenosis and aortic arch obstruction were present in one-third of subjects. In this cohort of infants requiring initial aortic arch repair with concomitant small left heart structures, successful BVC can be predicted from combined echocardiographic indices. In this complex population, 1 year survival is high, but the need for RI and the presence of residual lesions are common.

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Abbreviations

BVC:

Biventricular circulation

UVC:

Univentricular circulation

RI:

Re-intervention

MV:

Mitral valve

TV:

Tricuspid valve

AV:

Aortic valve

VSD:

Ventricular septal defect

ASD:

Atrial septal defect

Non-RI:

No re-intervention

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Author information

Author notes

  1. Jennifer M. Plymale

    Present address: Providence Center of Congenital Heart Disease at Sacred Heart Medical Center and Children’s Hospital in Spokane, 101 W 8th Ave Suite 4300, Spokane, WA, 99204, USA

  2. James S. Tweddell

    Present address: Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA

  3. Amanda J. Shillingford

    Present address: Nemours Cardiac Center, Alfred I. duPont Hospital for Children, Wilmington, DE, USA

Authors and Affiliations

  1. Department of Pediatrics, Division of Cardiology, Medical College of Wisconsin, Milwaukee, WI, USA

    Jennifer M. Plymale, Peter C. Frommelt & Amanda J. Shillingford

  2. Department of Pediatrics, Quantitative Health Sciences, Medical College of Wisconsin, Milwaukee, WI, USA

    Melodee Nugent & Pippa Simpson

  3. Department of Surgery, Division of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, WI, USA

    James S. Tweddell

Authors
  1. Jennifer M. Plymale
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Contributions

JMP—concept/design, data analysis/interpretation, drafting article, critical revision of article, approval of article, statistics, data collection. PCF—concept/design, data analysis/interpretation, drafting article, critical revision of article, approval of article. MN—data analysis/interpretation, critical revision of article, approval of article, statistics. PS—data analysis/interpretation, critical revision of article, approval of article, statistics. JST—critical revision of the article and approval of the article. AJS—concept/design, data analysis/interpretation, drafting article, critical revision of article, approval of article, statistics, data collection.

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Correspondence to Jennifer M. Plymale.

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Plymale, J.M., Frommelt, P.C., Nugent, M. et al. The Infant with Aortic Arch Hypoplasia and Small Left Heart Structures: Echocardiographic Indices of Mitral and Aortic Hypoplasia Predicting Successful Biventricular Repair. Pediatr Cardiol 38, 1296–1304 (2017). https://doi.org/10.1007/s00246-017-1661-2

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  • DOI: https://doi.org/10.1007/s00246-017-1661-2

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