The Anatomical or Functional Borderline Left Ventricle and Strategies for Staged Rehabilitation

  • Pedro J. del NidoEmail author


The concept of the “borderline left heart” was introduced following the experience with fetal catheter interventions that aimed to change the natural history of critical aortic stenosis in the fetus. Early attempts to rescue the severely obstructed left ventricle during mid-gestation by transuterine, balloon aortic valvotomy yielded encouraging results in some, with progressive recovery of left ventricle (LV) contractile function in the fetus and associated continued growth of the LV cavity as gestation progressed [1, 2]. However, in about 60 % of these patients, LV growth was inadequate, and at birth, the LV was deemed incapable of supporting the systemic circulation. The constellation of anatomic features varied from that seen in young infants with Shone’s syndrome with mitral and aortic valve stenosis and coarctation to that of hypoplastic left heart syndrome. These features included mitral valve stenosis and hypoplasia, aortic valve stenosis, and varying degrees of endocardial fibroelastosis. The latter appeared to develop in utero and we theorized that its presence restricted LV growth in utero and postnatally.


Left Ventricle Aortic Valve Hypoplastic Left Heart Syndrome Aortic Valve Stenosis Interatrial Communication 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. 1.
    McElhinney DB, Marshall AC, Wilkins-Haug LE, et al. Predictors of technical success and postnatal biventricular outcome after in utero aortic valvuloplasty for aortic stenosis with evolving hypoplastic left heart syndrome. Circulation. 2009;120:1482–90.CrossRefPubMedPubMedCentralGoogle Scholar
  2. 2.
    Freud LR, McElhinney DB, Marshall AC, et al. Fetal aortic valvuloplasty for evolving hypoplastic left heart syndrome postnatal outcomes of the first 100 patients. Prenat Diagn. 2014;31:695–8.Google Scholar
  3. 3.
    Han RK, Gurofsky RC, Lee KJ, et al. Outcome and growth potential of left heart structures after neonatal intervention for aortic valve stenosis. J Am Coll Cardiol. 2007;50:2406–14.CrossRefPubMedGoogle Scholar
  4. 4.
    McElhinney DB, Lock JE, Keane JF, et al. Left heart growth, function, and reintervention after balloon aortic valvuloplasty for neonatal aortic stenosis. Circulation. 2005;111:451–8.CrossRefPubMedGoogle Scholar
  5. 5.
    Kalish BT, Banka P, Lafranchi T, Tworetzky W, del Nido P, Emani SM. Biventricular conversion after single ventricle palliation in patients with small left heart structures: short-term outcomes. Ann Thorac Surg. 2013;96(4):1406–12.CrossRefPubMedGoogle Scholar
  6. 6.
    Xu X, Friehs I, Zhong Hu T, Melnychenko I, Tampe B, Alnour F, Iascone M, Kalluri R, Zeisberg M, del Nido PJ, Zeisberg EM. Endocardial fibroelastosis is caused by aberrant endothelial to mesenchymal transition. Circ Res. 2015;116(5):857–66.CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Tworetzky W, del Nido PJ, Powell AJ, Marshall AC, Lock JE, Geva T. Usefulness of magnetic resonance imaging of left ventricular endocardial fibroelastosis in infants after fetal intervention for aortic valve stenosis. Am J Cardiol. 2005;96(11):1568–70.CrossRefPubMedGoogle Scholar
  8. 8.
    Emani SM, Bacha EA, McElhinney DB, et al. Primary left ventricular rehabilitation is effective in maintaining two-ventricle physiology in the borderline left heart. J Thorac Cardiovasc Surg. 2009;138:1276–82.CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Emani SM, McElhinney DB, Tworetzky W, et al. Staged left ventricular recruitment following single ventricle palliation in patients with borderline left heart hypoplasia. J Am Coll Cardiol. 2012;60:1966–74.CrossRefPubMedGoogle Scholar
  10. 10.
    Baird CW, Myers PO, Borisuk M, Kalish B, Hofferberth S, Nathan M, Emani SM, del Nido PJ. Takedown of cavopulmonary shunt at biventricular repair. J Thorac Cardiovasc Surg. 2014;148(4):1506–11.CrossRefPubMedGoogle Scholar
  11. 11.
    Abdullah I, Ramirez FB, McElhinney DB, Lock JE, del Nido PJ, Emani S. Modification of a stented bovine jugular vein conduit (melody valve) for surgical mitral valve replacement. Ann Thorac Surg. 2012;94(4):e97–8.CrossRefPubMedGoogle Scholar
  12. 12.
    Quiñonez LG, Breitbart R, Tworetsky W, Lock JE, Marshall AC, Emani SM. Stented bovine jugular vein graft (Melody valve) for surgical mitral valve replacement in infants and children. J Thorac Cardiovasc Surg. 2014;148(4):1443–9.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing Switzerland 2016

Authors and Affiliations

  1. 1.Department of Cardiac SurgeryBoston Children’s Hospital, Harvard Medical SchoolBostonUSA

Personalised recommendations