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Infants with “borderline” left ventricles due to congenital aortic valve stenosis may be critically ill soon after birth since the left ventricle may be unable to sustain the complete systemic circulation. In these hearts, the stroke volume of the left ventricle is markedly decreased because of diminutive left ventricular internal dimensions. As the arterial duct closes in the first hours after birth, the left ventricle becomes responsible for generating the full systemic output. If the left heart is of borderline dimensions, this may lead to shock and even death. However, postnatal loading and growth conditions of the left ventricle differ significantly from foetal life and in so doing influence the postnatal course. Left ventricular growth potential remains and is likely to be stimulated by these physiological changes. Some may occur rapidly following birth whilst others may take weeks to months. Infants with borderline left ventricles present the physician with a unique dilemma: is this child able to tolerate a biventricular circulation or should one rather embark on a univentricular strategy? In recent years, experience with the hybrid procedure for hypoplastic left heart syndrome showed that indications may be extended to patients with critical aortic stenosis and borderline left heart. A hybrid procedure typically consists of surgical bilateral banding of the branch pulmonary arteries in combination with placement of a stent in the ductus arteriosus after balloon angioplasty of the stenosed aortic valve (Fig 1). As a result, a parallel circulation is created and the right heart can support the left heart to maintain adequate systemic output. This “buys time” to observe the growth potential of the left heart and allows the physician more room to make an informed decision regarding univentricular or biventricular long-term strategy. In this chapter we describe the background, possibilities, technical aspects and results of this strategy in neonates with critical aortic stenosis and borderline left heart.

Hybrid Procedure in Neonatal Critical Aortic Stenosis and Borderline Left Heart: Buying Time for Left Heart Growth