Surgical strategies to facilitate heart transplantation in children after failed univentricular palliations: the role of advanced intraoperative surgical preparation

Objectives: Heart transplantation in children after univentricular palliation is a technical challenge. As the national referral centre for heart transplantation in children, we review national trends in transplantation and describe technical innovations used in the current era.

Methods: Children undergoing heart transplantation were separated into patients with (i) structural congenital heart disease (sCHD; subdivided into univentricular and biventricular) and (ii) cardiomyopathy (CM). The operation notes and surgeons' diagrams were reviewed with particular attention to surgical innovations introduced after 2000.

Results: Between January 1988 and December 2012, 111 primary transplantations were performed: 50 for sCHD (30 univentricular and 20 biventricular) and 61 for CM. Thirty-day mortality for univentricular patients compared to those with CM was significantly higher before 2000 (21 vs 0%, 3/14 vs 0/20, P = 0.023) and not different after 2000 (8 vs 6%, 3/38 vs 1/16, P = 0.852). At the same time, the percentage of patients with univentricular physiology increased from 47% (14 of 30 patients) to 80% (16 of 20 patients) versus those with biventricular physiology. After 2000, 12 of 16 patients (75%) with univentricular sCHD required reconstruction of the great vessels. Of these, 8 (50%) patients had reached the stage of Fontan, 5 had reached bidirectional cavopulmonary shunt, 2 had reached Kawashima procedure and 1 had only a Blalock-Taussig shunt. The following techniques were employed in 12 transplantations: aortic arch replacement (n = 3), hilum-to-hilum pulmonary artery (PA) reconstruction (n = 5), PA patch reconstruction (n = 5), reconstruction of the PA bifurcation using donor bifurcation (n = 2) and left superior vena cava (SVC) to donor SVC reconstruction (n = 3).

Conclusions: In the current era, the majority of children undergoing heart transplantation for sCHD have had univentricular palliation. These patients pose challenges because of prior surgeries and complex anatomy, but the techniques described here in may enable improved outcome.