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(Circulation. 2004;109:2326-2330.)
© 2004 American Heart Association, Inc.

Clinical Investigation and Reports

Hypoplastic Left Heart Syndrome With Intact or Highly Restrictive Atrial Septum

Outcome After Neonatal Transcatheter Atrial Septostomy

Antonios P. Vlahos, MD; James E. Lock, MD; Doff B. McElhinney, MD; Mary E. van der Velde, MD

From the Departments of Cardiology, Children’s Hospital, and Pediatrics, Harvard Medical School, Boston, Mass. Dr van der Velde is now at the Division of Pediatric Cardiology, University of Michigan Health System, Ann Arbor.

Correspondence to Mary E. van der Velde, MD, Associate Professor of Pediatrics, Division of Pediatric Cardiology, University of Michigan Health System, L1242 Women’s, Box 0204, 1500 East Medical Center Dr, Ann Arbor, MI 48109-0204. E-mail mvdvelde{at}med.umich.edu

Received October 8, 2003; revision received February 6, 2004; accepted February 10, 2004.

Background— Hypoplastic left heart syndrome (HLHS) with intact or very restrictive atrial septum is a highly lethal combination. We review our 13-year institutional experience treating this high-risk subgroup of patients with emergent catheter therapy.

Methods and Results— Infants with HLHS requiring catheter septostomy within the first 2 days of life were compared with a matched control group with adequate interatrial communication. Preoperative, early postoperative, and medium-term survival were evaluated. Earlier experience was compared with recent results to assess the effect of changes in catheterization and surgical and intensive care unit management strategies over the study period. From 1990 to 2002, 33 newborns with HLHS (11% of newborns with HLHS managed during this period) underwent urgent/semiurgent catheterization to create or enlarge an interatrial communication before surgical palliation. Preoperative and early postoperative mortality were high (48%) compared with control HLHS patients, regardless of prenatal diagnosis and despite successful catheter-based atrial septostomy with clinical stabilization. Mortality trended down during the later part of the study period. Those who survived the neonatal period had late survival, pulmonary artery pressure, and resistance similar to those of control subjects.

Conclusions— Neonatal mortality in the subgroup of HLHS patients with intact or highly restrictive atrial septum remains high despite successful urgent septostomy. Persistently poor outcomes for these patients have prompted efforts at our center to develop techniques for fetal intervention for this condition, in the hope that prenatal relief of left atrial and pulmonary venous hypertension may promote normal pulmonary vascular and parenchymal development and improve both short- and long-term outcomes.

Key Words: heart defects, congenital • pediatrics • catheterization • pregnancy

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