Echocardiographic factors discriminating biventricular versus univentricular approach in the foetus with borderline left ventricle

Background: The term "borderline left ventricle" describes a small left heart that may be inadequate to provide systemic cardiac output and implies the potential need for a single-ventricle palliation. The aim of this study was to identify foetal echocardiographic features that help discriminate which infants will undergo single-ventricle palliation versus biventricular repair to aid in prenatal counselling. Methods: The foetal database at our institution was searched to identify all foetuses with borderline left ventricle, as determined subjectively by a foetal cardiologist, from 2000 to 2011. The foetal images were retrospectively analysed for morphologic and physiologic features to determine which best predicted the postnatal surgical choice. Results: Of 39 foetuses identified with borderline left ventricle, 15 were planned for a univentricular approach, and 24 were planned for a biventricular approach. There were significant differences between the two outcome groups in the Z-scores of the mitral valve annulus, left ventricular end-diastolic dimension, aortic valve annulus, and ascending aorta diameter (p<0.05). With respect to discriminating univentricular outcomes, cut-offs of mitral valve Z-score ≤-1.9 and tricuspid:mitral valve ratio ≥1.5 were extremely sensitive (100%), whereas a right:left ventricular end-diastolic dimension ratio ≥2.1 provided the highest specificity (95.8%). Conclusion: In foetuses with borderline left ventricle, a mitral valve Z-score ≥-1.9 or a tricuspid:mitral valve ratio ≤1.5 suggests a high probability of biventricular repair, whereas a right:left ventricular end-diastolic dimension ratio ≥2.1 confers a likelihood of single-ventricle palliation.