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Pathological changes and myocardial remodelling related to the mode of shunting following surgical palliation for hypoplastic left heart syndrome*

Published online by Cambridge University Press:  01 August 2008

Massimo A. Padalino ,
Chiara Castellani ,
Silvia Toffoli ,
Mila Della Barbera ,
Ornella Milanesi ,
Gaetano Thiene ,
Giovanni Stellin  and
Annalisa Angelini
Massimo A. Padalino*
Affiliation:
Pediatric and Congenital Cardiovascular Surgery Unit, University of Padua, Medical School, Padua, Italy
Chiara Castellani
Affiliation:
Cardiovascular Pathology, University of Padua, Medical School, Padua, Italy
Silvia Toffoli
Affiliation:
Cardiovascular Pathology, University of Padua, Medical School, Padua, Italy
Mila Della Barbera
Affiliation:
Cardiovascular Pathology, University of Padua, Medical School, Padua, Italy
Ornella Milanesi
Affiliation:
Pediatric Cardiology, University of Padua, Medical School, Padua, Italy
Gaetano Thiene
Affiliation:
Cardiovascular Pathology, University of Padua, Medical School, Padua, Italy
Giovanni Stellin
Affiliation:
Pediatric and Congenital Cardiovascular Surgery Unit, University of Padua, Medical School, Padua, Italy
Annalisa Angelini
Affiliation:
Cardiovascular Pathology, University of Padua, Medical School, Padua, Italy
*
Correspondence to: Massimo A. Padalino, MD, PhD, Pediatric and Congenital Cardiovascular Surgery Unit, Centro “Vincenzo Gallucci”, University of Padua Medical School, Via Giustiniani 2, 35128 Padua, Italy. Tel: +39-049-8212427; Fax: +39-049-8212409; E-mail: [email protected]
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Abstract

Background

The modification of placing the shunt from the right ventricle to the pulmonary arteries, also known as Sano procedure, has allegedly improved results over the short term in surgical palliation of hypoplastic left heart syndrome with the Norwood procedure. With this in mind, we reviewed autopsied specimens from neonates and children who did not survive after either a classic arterio-pulmonary shunt, or the modified procedure with the shunt placed from the right ventricle to the pulmonary arteries, so as to evaluate the pathological substrates of the remodelling of the systemic right ventricle, assessing any differences induced by the 2 techniques.

Methods

We obtained the hearts from 11 patients with neonatal diagnosis of hypoplastic left heart syndrome who died after the first or second stages of the Norwood sequence of operations, comparing them with 6 normal hearts matched for age and weight. Macroscopic, microscopic and morphometric analysis were performed on each specimen, evaluating the diameter of the myocytes, extracellular matrix remodelling in terms of fibrosis and type of collagen, and vascularization in terms of capillary density.

Results

Hypertrophy of the myocytes was significantly increased in the hearts from patients having either a classic arterio-pulmonary or the ventriculo-pulmonary modification of the shunt compared to controls (p < 0.05). Myocardial fibrosis was increased in those having a shunt placed from the right ventricle to the pulmonary arteries when compared to the other 2 groups. The ratio of collagen I to collagen III was similar in those undergoing a classic arterio-pulmonary shunt compared to controls (0.94), but was lower in those having a shunt placed from the right ventricle to the pulmonary arteries (0.61), with an increase in collagen type III. The density of capillaries was lower in those who had undergone a classic arterial shunt when compared to the others.

Conclusion

We have shown greater remodelling of the ventricular myocardial extracellular matrix in patients having a shunt from the right ventricle to the pulmonary arteries when compared to those having a classic arterio-pulmonary shunt, with this remodelling progressing even after the neonatal period. This may influence a later suboptimal ventricular performance.

Keywords

Hypoplastic left ventriclesurgeryfibrosisventricular functionpathology
Type
Original Article
Information
Cardiology in the Young , Volume 18 , Issue 4 , August 2008 , pp. 415 - 422
Copyright
Copyright © Cambridge University Press 2008

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Footnotes

*

Supported by Cardio-Cerebral Pathology Registry, Regione Veneto, Venice, Italy.

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