Original Article Staged Palliation of Cyanotic Obstructive Lesions With a Modified Right Ventricular Outflow Procedure Sarosh P. Batlivala, MD 1,2 , Mary K. Hood, BS 1 , Jannika Dodge-Khatami, MD 1,2 , Divya Shakti, MD, MPH 1,2 , Mary B. Taylor, MD, MSCI 1,2 , Makram R. Ebeid, MD 1,2 , Jorge D. Salazar, MD 4 , and Ali Dodge-Khatami, MD, PhD 1,3 Abstract Background: Traditional palliation for biventricular cyanotic congenital heart lesions often involves staging with systemic-to- pulmonary arterial shunts to secure pulmonary blood flow (PBF) in the newborn period prior to complete repair. However, shunts may lead to life-threatening events secondary to shunt occlusion or acute coronary steal. They may be associated with morbidity secondary to diastolic runoff, systemic steal and volume loading, and do not provide pulsatile flow which has the potential to promote pulmonary artery (PA) growth. We have alternatively performed modified right ventricular outflow (mRVO) procedures by establishing antegrade right ventricle-to-PA flow. Methods: Retrospective review of data on all patients who underwent the mRVO procedure from 2013 to 2016, including anatomy, number of interstage catheterizations, reopera- tions, intensive care unit admissions, hypercyanotic episodes, interval to complete repair, and mortality. Results: Seventeen nonconsecutive patients included tetralogy of Fallot (n ¼ 14), pulmonary valve stenosis (n ¼ 2), and 1 with pulmonary atresia- intact septum; 14 had significant branch PA stenosis. Median age of first mRVO procedure was 14 days (range 5-193), and median duration of follow-up was 15.3 months (range 4-47 months). No patients had post-palliation acute hypercyanotic episodes. Nine were admitted to the ICU for persistent interstage hypoxemia, 7 of whom required reintervention prior to complete repair, which was achieved in 11 patients. Two late deaths unrelated to mRVO occurred. Conclusions: The mRVO procedure is a potential option with satisfactory results. It avoids potential shunt-related sudden death. The physiology of the mRVO palliation may provide unique benefits by providing antegrade pulsatile PBF, facilitates catheter interventions, and avoids branch PA distortion and stenosis. Keywords CHD, tetralogy, CHD, pulmonary arteries, cyanosis Submitted July 07, 2017; Accepted September 29, 2017 Presented at the 40th Annual Meeting of the Society for Cardiovascular Angiography and Interventions; New Orleans, USA; May 10-13, 2017. Introduction Cyanotic biventricular congenital heart disease (CHD) lesions often require palliation prior to complete repair in order to augment or secure pulmonary blood flow (PBF) in the newborn period. 1-4 Traditionally, systemic-to-pulmonary artery (PA) shunts are placed to either increase or provide the only source of pulmonary flow, in lieu of the more difficult to control flow via a patent ductus arteriosus (PDA). 5 More recently, in low- birth-weight patients and/or in those with significant aortic arch branching anomalies, systemic-PA shunting is challenging or carries a higher risk of operative or interstage mortality, for which the right ventricle-PA shunt has been advocated with satisfactory results. 6 However, all shunts require postoperative antiaggregant therapy and have associated problems including 1 School of Medicine, University of Mississippi Medical Center, Jackson, MS, USA 2 Division of Pediatric Cardiology, Batson Children’s Hospital, University of Mississippi Medical Center, Jackson, MS, USA 3 Division of Pediatric and Congenital Heart Surgery, Batson Children’s Hospital, University of Mississippi Medical Center, Jackson, MS, USA 4 Department of Cardiac Surgery, Boston Children’s Hospital, Harvard University, Boston, MA, USA Corresponding Author: Ali Dodge-Khatami, Division of Pediatric and Congenital Heart Surgery Batson, Children’s Hospital, University of Mississippi Medical Center, 2500 North State Street, Room S345, Jackson, MS 39216, USA. Email: adodgekhatami@umc.edu World Journal for Pediatric and Congenital Heart Surgery 2018, Vol. 9(1) 68-73 ª The Author(s) 2017 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/2150135117738007 journals.sagepub.com/home/pch