Hypoplastic Left Heart Syndrome, Interrupted Inferior Vena Cava, Biliary Atresia

Extracardiac anomalies in prenatally diagnosed heterotaxy syndrome

OBJECTIVE

To assess the incidence and impact of extracardiac anomalies on the prognosis of fetuses with heterotaxy syndrome.

METHODS

All fetuses diagnosed with heterotaxy syndrome by three experienced examiners over a period of 14 years (1999-2013) were reviewed retrospectively.

RESULTS

In total, 165 fetuses with heterotaxy syndrome were diagnosed in the study period. One hundred and fifty (90.9%) had cardiac defects; extracardiac anomalies that did not involve the spleen were present in 26/165 (15.8%) cases. Of the total study cohort, termination of pregnancy was performed in 49 (29.7%) cases, intrauterine death occurred in 11 (6.7%), postnatal death occurred in 38 (23.0%) and 67 (40.6%) were alive at the latest follow-up, resulting in a total perinatal and pediatric mortality of 59.4%. Among the 105 liveborn neonates, 15 (14.3%) had extracardiac anomalies with significant impact on the postnatal course: one neonate died following repair of an encephalocele, six had successful treatment for various types of intestinal malrotation and/or atresia and one underwent hiatal hernia repair; the remaining seven had biliary atresia, of which five died and the two survivors are awaiting liver transplantation. The status of the spleen was assessed in 93/105 liveborn children and was found to be abnormal in 84/93 (90.3%). There were three cases of lethal sepsis, all associated with asplenia. Of the 38 postnatal deaths, 29 (76.3%) had a cardiac cause, seven (18.4%) had an extracardiac cause and in two (5.2%) the reason was uncertain.

CONCLUSIONS

Although the leading causes of death in fetuses and children with heterotaxy syndrome are cardiac, a small subset of fetuses have extracardiac anomalies with significant impact on outcome. These anomalies often escape prenatal detection, and therefore neonates at risk should be monitored for bowel obstruction, biliary atresia and immune dysfunction in order to allow timely intervention through a multidisciplinary approach. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

Liver transplantation after stage II palliation for hypoplastic left heart syndrome

The association of biliary atresia (BA) with congenital heart diseases has been extensively described, and there are a number of reports on the outcomes of patients in this group who undergo liver transplantation (LT). The intraoperative management and the timing of LT for patients with end-stage liver disease are matters of debate, especially when complex heart diseases are involved. This report describes the outcome after LT for a pediatric recipient with BA and hypoplastic left heart syndrome. The patient underwent Norwood-Sano and Glenn procedures for heart palliation before LT. He was cyanotic, was severely malnourished, and had complications secondary to chronic liver failure. At the time of transplantation, the child was 16 months old and weighed 5175 g. Despite the critical clinical scenario and the long hospitalization period, there were no cardiac, vascular, or biliary complications after LT. At the age of 48 months, the patient was awaiting the final cardiac repair. In conclusion, the presence of complex cardiac malformations may not be a contraindication to LT. An experienced surgical team and a multidisciplinary approach are key to a successful outcome.

The bilateral pulmonary artery banding for hypoplastic left heart syndrome with a diminutive ascending aorta

A one-day-old neonate who was diagnosed with hypoplastic left heart syndrome (HLHS), aortic atresia, with a diminutive ascending aorta, and mitral atresia, was referred to us for cardiogenic shock because of excessive pulmonary blood flow. The patient underwent bilateral pulmonary artery banding (bPAB). After bPAB, the patient's hemodynamics were still unstable because of coronary malperfusion, to proceed to undergo Norwood procedure at the age of 3 days. In this case, the stenosis of the ascending aorta, just proximal to the innominate artery caused coronary ischemia. The precise evaluation of the ascending aorta is necessary to perform the bPAB for HLHS with diminutive ascending aorta. If there is a sign of stenosis of the ascending aorta, the Norwood procedure should be performed as the first stage palliation, even for high-risk HLHS patients.