Allograft root on closed pulmonary valve for subaortic obstruction in double-inlet left ventricle with transposition of the great arteries

Background. Until recently closure of the pulmonary valve during staged Fontan-type palliation in the setting of double-inlet left ventricle with an unrestrictive or adequately enlarged ventricular septal defect and transposition of the great arteries with the aorta on a left-sided outflow chamber was regarded as an appropriate part of surgical treatment. Lately, however, an increased incidence of subsequent subaortic obstruction has been described in this regard. Methods. Allograft root placement on the previously closed pulmonary orifice in combination with a modified Damus-Kaye-Stansel procedure is described to create an unobstructed outflow from the main ventricle to the systemic circulation. This procedure was done in 3 patients. One root placement was combined with the construction of the bidirectional superior cavopulmonary connection, one was done as an intermediate step before completion of the cavopulmonary connection, and one was combined with completion of total cavopulmonary connection. Results. Immediate relief of the subaortic obstruction was achieved in all 3 patients. Ventricular hypertrophy, echocardiographically assessed by diastolic posterior wall thickness, regressed to normal in all 3 within 6 to 12 months. Conclusions. Allograft root placement on the reopened pulmonary orifice in double-inlet left ventricle with a ventricular septal defect and transposition of the great arteries appears technically feasible and functionally adequate on short-term follow-up. This procedure should result in regression of ventricular hypertrophy to allow eligibility for a Fontan-type palliation again. To what extent possible failure of the allograft increases the risk of an adverse outcome of this palliation may be a matter of concern.