Factors Associated with Morbidity, Mortality, and Hemodynamic Failure after Biventricular Conversion in Borderline Hypoplastic Left Hearts

Published:January 23, 2023DOI:
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      A subset of patients with borderline hypoplastic left heart (BHLH) may be candidates for single to biventricular conversion (BiVC), but long-term morbidity and mortality persist. Prior studies have conflicted regarding the association of preoperative diastolic dysfunction and outcome, and patient selection remains challenging.


      Patients with BHLH undergoing BiVC from 2005-2017 were included. Cox regression identified preoperative factors associated with a composite outcome of time to mortality, heart transplant, takedown to single ventricle circulation, or hemodynamic failure (defined as left ventricular end diastolic pressure [LVEDP] >20 mmHg, mean pulmonary artery pressure >35 mmHg, or pulmonary vascular resistance >6 iWU).


      Among 43 patients, 20 (46%) met the outcome, with a median time to outcome of 5.2 years. On univariate analysis, endocardial fibroelastosis (EFE), lower LV end-diastolic volume/body surface area (BSA) (when <50 ml/m2), lower LV stroke volume/BSA (SVi, when <32 ml/m2), and lower left:right ventricular SV ratio (when <0.7) were associated with outcome; higher preoperative LVEDP was not. Multivariable analysis demonstrated that EFE (hazard ratio [HR] 5.1, 95% CI 1.5-22.7, p=0.033) and LV SVi <28 ml/m2 (HR 4.3, 95% CI 1.5-12.3, p=0.006) were independently associated with higher hazard of the outcome. Nearly all (86%) patients with EFE and LV SVi <28 ml/m2 met the outcome compared to 10% of those without EFE and with higher SVi.


      History of EFE and smaller LV SVi are independent factors associated with adverse outcome among patients with BHLH undergoing BiVC. Normal preoperative LVEDP is insufficient to reassure against diastolic dysfunction after BiVC.

      Graphical abstract


      Glossary of Abbreviations:

      BHLH (borderline hypoplastic left heart), BiVC (biventricular conversion), BSA (body surface area), CMR (cardiac magnetic resonance), EDVi (end diastolic volume/body surface area), EF (ejection fraction), EFE (endocardial fibroelastosis), HR (hazard ratio), LVEDP (left ventricular end diastolic pressure), LV (left ventricular), PVR (pulmonary vascular resistance), SVi (stroke volume/body surface area)
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