Don't Give up on the Left Ventricle! Surgical Strategies for Recruitment of the Borderline Left Heart

Patients with hypoplastic left heart syndrome often undergo a definitive decision in infancy regarding lifetime circulatory management. However, the decision between single ventricle palliation or primary biventricular repair is less obvious for patients with ‘borderline left heart’ structures. An alternative strategy for the patient with borderline left heart is staged left ventricular recruitment (SLVR). SLVR refers to the strategy in which initial stage I palliation is pursued, and interstage procedures are then performed to promote flow through the left heart and induce growth of left heart structures. If ventricular response to SLVR is robust, eventual biventricular conversion can be pursued. At our institution, 53 patients have undergone (or are undergoing) SLVR for hypoplastic left heart syndrome, with 29 patients successfully progressing to biventricular or 1.5 ventricle repair. This paper outlines the rationale and management strategy of SLVR from the past two decades of our center's experience.