Damus-Kaye-Stanzel vs Bulboventricular Foramen resection

Damus-Kaye-Stanzel vs
Bulboventricular Foramen
resection
Emile Bacha, MD
Director, Pediatric Cardiac Surgery
Morgan Stanley Children’s Hospital of New York-Presbyterian
Columbia University Medical Center

Frame the problem
• Tricuspid atresia with d-TGA
• DILV (S,L,L)
• Rare forms of single V, unrestricted
pulmonary blood flow and
subaortic systemic obstruction

Lets agree on a few principles
1. Surgical strategy largely determined by:
– BVF
– Semilunar valves
– (aortic arch)

Lets agree on a few principles
1. Surgical strategy largely determined by:
– BVF
– Semilunar valves
– (aortic arch)
2. BVF resection is not applicable during neonatal
period (exposure, friable tissue)

Lets agree on a few principles
1. Surgical strategy largely determined by:
– BVF
– Semilunar valves
– (aortic arch)
2. BVF resection is not applicable during neonatal
period (exposure, friable tissue)
Therefore, if subAS (restrictive BVF) is severe
enough to warrant resection, then DKS/Norwood
is necessary (palliative switch?)

Lets agree on a few principles
1. Surgical strategy largely determined by:
– BVF
– Semilunar valves
– (aortic arch)
2. BVF resection is not applicable during neonatal period (exposure, friable
tissue)
Therefore, if subAS (restrictive BVF) is severe enough to warrant resection, then
DKS/Norwood is necessary (palliative switch?)
3. If there is aortic arch obstruction, Norwood

Does PA banding really increase the
chances of restriction

How do you determine if a
BVF is restrictive, or will be
restrictive?

• a systemic outflow gradient at the subvalvular
level

• a systemic outflow gradient at the subvalvular
level
or
• a bulboventricular foramen/aortic valve
diameter ratio of 1 or less

You are more likely to end up with obstruction if the BVF is small
to begin with

If the aortic arch is obstructed, the BVF is more likely to be small

Patients WITHOUT aortic arch obstruction: patients who developed
BVF obstruction had sign. smaller BVF index area

Conclusions (Matitiau et al)
• Neonate with a BVF size index of < 2cm 2 /m 2
are at high risk for developing BVF obstruction

What happens to the BVF even if
you DON’T band the PA?

Modified Norwood Operation for Single Left
Ventricle and Ventriculoarterial Discordance: An
Improved Surgical Technique.
Mosca, Bove et al
Ann Thorac Surg 1997;64:1126-1132

• N=20: Although the absolute bulboventricular
foramen size did increase in approximately 50%
of patients, this was not predictable, and when
indexed to body surface area, there was an
overall decrease with time (20%)

Management strategies:
DKS vs BVF resection (or other non
“arch” procedures)

BVF resection

BVF resection
• Usually in older patients who have been banded
and started out with large BVFs

BVF resection:
location of the conduction system
Anderson R. H. et al.; Ann Thorac Surg 1998;66:644-648

Technique of DKS (Norwood) in
setting of d-TGA or l-TGA

Mosca et al, ATS 1997

Mosca et al, ATS 1997

Mosca et al, ATS 1997

Conclusion
• For patients with single ventricle, unrestrictive
pulmonary blood flow and an aorta arising from
an outflow chamber connected to the main
ventricle via a BVF (usually DILV/SLL or
Tricuspid Atresia/d-TGA)

Conclusions
• BVF size in the neonate is an important
predictor of late obstruction
• Neonate with a BVF size index of < 2cm2 /m2 • Neonate with a BVF size index of < 2cm2 /m2 are at high risk for developing BVF obstruction
• Although the BVF appears to grow, its growth
does not keep pace with somatic growth in most
patients

Conclusion (management)
• If there is AS or aortic arch hypoplasia:
Norwood

Conclusion (management)
• If there is AS or aortic arch hypoplasia:
Norwood
• If there is any evidence of subAS (restrictive
• If there is any evidence of subAS (restrictive
BVF): Norwood

Conclusion (management)
• If there is AS or aortic arch hypoplasia:
Norwood
• If there is any evidence of subAS (restrictive
BVF): Norwood
• For patients with no AS/ao arch hypoplasia and
large BVF, PAB may be an option (very rare!)