Pediheart: Pediatric Cardiology Today
Oct 16, 2026 · 44 min · 12 segments
This week we review a recent report from the team at UTSW comparing early outcomes following biventricular repair vs. Fontan palliation for complex congenital heart disease with borderline ventricles…
Robert PassHostAbhay DivekarGuestNicholas AndersenGuest
The work begins with some comments about patients who have single ventricle disease with borderline ventricles, or alternatively, patients with two ventricles that are of adequate size, but with complex cardiac anatomy that might make achieving two ventricle circulation a challenge, but who might be able to achieve such either via a single complex operation or staged repairs or even ventricular recruitment procedures.
The authors then point to some smaller series that have previously suggested better survival and maybe even lower degrees of liver disease amongst those who have undergone these approaches versus the Fontan.
And they remind that the impetus to do this is perhaps even stronger in certain subsets of patients, such as patients with trisomy 21 or heterotaxy syndrome, where outcomes of single ventricle palliation are perhaps somewhat worse.
They then review one of the most important reasons that teams will lean on the Fontan in these sorts of cases, and this is the concern that there will be higher procedural morbidity with biventricular repair, including things like a longer hospital stay, unplanned reintervention, or simple failure of biventricular circulation.
They then explain that since 2023, the group at UT Southwestern has a dedicated complex biventricular repair team and further explain that the goal of this study was to, quote, "Compare procedural and one-year outcomes between patients undergoing complex biventricular repair and Fontan operations to ascertain real-world differences in the ease of early recovery between these two alternatives.
We hypothesized that contemporary short-term outcomes of biventricular repair would approximate those of Fontan procedures in well-selected patients because of improvements in patient selection, 3D imaging, surgical approach, and postoperative recovery strategies." This was a retrospective study at UT Southwestern, and the authors explained that their complex biventricular repair team includes a dedicated care conference with a dedicated nurse practitioner, 3D virtual imaging planning before each procedure, two attending surgeons for each operation, protocolized postoperative care, as well as a dedicated interstage monitoring and surveillance team.
This study included anyone who had a complex biventricular repair from 2023 to 2025 at that center and excluded newborns with borderline ventricles who had a neonatal repair.
Also excluded were mildly unbalanced complete AV canal patients who had primary stage repairs.
The authors explained that this was effectively a group of patients who, prior to 2023, would have definitely at the center be sent down the single ventricle route.
They divided these sorts of patients into three types: those with borderline LV, those with a borderline RV, and those who had two good ventricles, but complex intracardiac anatomy or coronary anatomy that led to concerns regarding feasibility of septation.
And for this work, a borderline ventricular volume was less than 45 milliliters per meter squared.
The authors compared these cases to those with similar anatomy from 2018 to 2025 from their own internal STS database.
During the study time, there were 40 patients who went down the biventricular rabbit hole and who underwent a total of 51 surgical biventricular repair procedures and 155 patients who underwent Fontan operations.
And Table 1 reviews the anatomy of these patients, as well as the staged repairs that they underwent.
Of the patients with small RV who had an MRI, of which there were 13, the mean RV end-diastolic volume was 36 milliliters per meter squared.
And for the patients with borderline LV, of which again there were 11, nine had CMRs with a mean LV end-diastolic volume of 41.
There were no patients with LV endocardial fibroelastosis, which is an important negative, as we know that other groups do not necessarily view this as a contraindication to this sort of approach.
And so again, between 2023 and 2025, 40 patients previously considered for single ventricle palliation underwent 51 biventricular operations at a median age of 1.1 years.
16 patients underwent staged biventricular repair, and four were still awaiting completion of the second stage.
The comparison group consisted again of 155 patients undergoing Fontan operations between 2018 and 2025 at a median of 4.2 years.
During the perioperative period, there were no deaths in the biventricular group compared with eight deaths, or 5.2%, in the Fontan group.
The work begins with some comments about patients who have single ventricle disease with borderline ventricles, or alternatively, patients with two ventricles that are of adequate size, but with complex cardiac anatomy that might make achieving two ventricle circulation a challenge, but who might be able to achieve such either via a single complex operation or staged repairs or even ventricular recruitment procedures.
The authors then point to some smaller series that have previously suggested better survival and maybe even lower degrees of liver disease amongst those who have undergone these approaches versus the Fontan.
And they remind that the impetus to do this is perhaps even stronger in certain subsets of patients, such as patients with trisomy 21 or heterotaxy syndrome, where outcomes of single ventricle palliation are perhaps somewhat worse.
They then review one of the most important reasons that teams will lean on the Fontan in these sorts of cases, and this is the concern that there will be higher procedural morbidity with biventricular repair, including things like a longer hospital stay, unplanned reintervention, or simple failure of biventricular circulation.
They then explain that since 2023, the group at UT Southwestern has a dedicated complex biventricular repair team and further explain that the goal of this study was to, quote, "Compare procedural and one-year outcomes between patients undergoing complex biventricular repair and Fontan operations to ascertain real-world differences in the ease of early recovery between these two alternatives.
We hypothesized that contemporary short-term outcomes of biventricular repair would approximate those of Fontan procedures in well-selected patients because of improvements in patient selection, 3D imaging, surgical approach, and postoperative recovery strategies." This was a retrospective study at UT Southwestern, and the authors explained that their complex biventricular repair team includes a dedicated care conference with a dedicated nurse practitioner, 3D virtual imaging planning before each procedure, two attending surgeons for each operation, protocolized postoperative care, as well as a dedicated interstage monitoring and surveillance team.
This study included anyone who had a complex biventricular repair from 2023 to 2025 at that center and excluded newborns with borderline ventricles who had a neonatal repair.
Also excluded were mildly unbalanced complete AV canal patients who had primary stage repairs.
The authors explained that this was effectively a group of patients who, prior to 2023, would have definitely at the center be sent down the single ventricle route.
They divided these sorts of patients into three types: those with borderline LV, those with a borderline RV, and those who had two good ventricles, but complex intracardiac anatomy or coronary anatomy that led to concerns regarding feasibility of septation.
And for this work, a borderline ventricular volume was less than 45 milliliters per meter squared.
The authors compared these cases to those with similar anatomy from 2018 to 2025 from their own internal STS database.
During the study time, there were 40 patients who went down the biventricular rabbit hole and who underwent a total of 51 surgical biventricular repair procedures and 155 patients who underwent Fontan operations.
And Table 1 reviews the anatomy of these patients, as well as the staged repairs that they underwent.
Of the patients with small RV who had an MRI, of which there were 13, the mean RV end-diastolic volume was 36 milliliters per meter squared.
And for the patients with borderline LV, of which again there were 11, nine had CMRs with a mean LV end-diastolic volume of 41.
There were no patients with LV endocardial fibroelastosis, which is an important negative, as we know that other groups do not necessarily view this as a contraindication to this sort of approach.
And so again, between 2023 and 2025, 40 patients previously considered for single ventricle palliation underwent 51 biventricular operations at a median age of 1.1 years.
16 patients underwent staged biventricular repair, and four were still awaiting completion of the second stage.
The comparison group consisted again of 155 patients undergoing Fontan operations between 2018 and 2025 at a median of 4.2 years.
During the perioperative period, there were no deaths in the biventricular group compared with eight deaths, or 5.2%, in the Fontan group.
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