Reconsidering Biventricular Repair in Complex Congenital Heart Disease

For children with borderline ventricular size or complex congenital heart disease, one question often shapes long-term management: Can this child ultimately support a two-ventricle circulation?

Historically, many of these patients were directed toward the single-ventricle pathway because biventricular repair was considered technically infeasible. Today, advances in imaging, staged reconstruction, and ventricular recruitment are expanding treatment options for carefully selected patients.

As experience with complex biventricular repair continues to grow, clinicians are recognizing that candidacy may be more dynamic than previously believed. For some children, an early assessment or reassessment later in their course can reveal new possibilities.

Not Every Patient Fits Traditional Pathways

Determining the optimal circulation strategy remains one of the most challenging decisions in congenital heart disease treatment.

Children with borderline ventricles, unbalanced atrioventricular canal defects, heterotaxy syndrome, double-outlet right ventricle and other complex anatomy often fall into a gray area where neither a single ventricle pathway nor biventricular repair is clearly the best option.

While the Fontan circulation remains the appropriate strategy for many patients, it’s important to identify children who may benefit from additional evaluation before committing to a lifelong single-ventricle pathway.

In some cases, ventricular growth, staged interventions, or advanced reconstructive techniques can create treatment opportunities that were not apparent during infancy. Especially when single ventricle palliation was the chosen strategy because of the complexity of the anatomy or because of an unbalanced canal, there are now opportunities to still achieve a biventricular circulation even if the patient has undergone a BiDirectional Glenn (BDG) or Fontan procedure. Cincinnati Children’s has performed Fontan reversal and complex repair to create a biventricular circulation even in Fontan patients who are adolescents or into their 20s.

Looking Beyond Traditional Criteria

Determining candidacy for biventricular repair requires more than measuring ventricular size.

At Cincinnati Children's, pediatric cardiologists, cardiothoracic surgeons, cardiac imagers, interventional cardiologists, virtual reality engineers and critical care specialists work together to evaluate each patient from multiple perspectives.

The team considers:

• Ventricular size and function
• Atrioventricular valve anatomy
• Intracardiac relationships
• Outflow tract anatomy
• Hemodynamics
• Potential for ventricular recruitment over time

Advanced echocardiography, cardiac MRI, cardiac catheterization and 3D modeling help determine whether a child may ultimately support a two-ventricle circulation. Cincinnati Children’s ability to do the most complex repairs is enhanced by a Virtual Reality Surgical (VR3S) Platform developed there, which allows surgeons to do a trial surgery and try different techniques before even going into the operating room. This platform also enables Cincinnati Children’s to review and plan out cases with other programs and surgeons all over the US and the world in the virtual space.

How Virtual Surgical Planning Supports Complex Biventricular Repair

For some patients, staged interventions provide an opportunity to reassess candidacy as cardiac structures grow and physiology evolves, creating options that may not have existed at the initial evaluation.

Evidence Continues to Expand Treatment Options

Growing surgical experience continues to reshape how clinicians think about complex biventricular repair.

Recent studies have reported successful staged biventricular conversion in children with borderline ventricular hypoplasia and have described new reconstructive approaches following hybrid palliation and, in select cases, even after Fontan circulation. Although careful patient selection remains essential, these findings reinforce that candidacy for biventricular repair is not always fixed.

When to Refer

Referral may be appropriate for children with:

• Borderline ventricular anatomy
• Evolving ventricular adequacy
• Heterotaxy-associated congenital heart disease
• Unbalanced atrioventricular canal defects
• Uncertainty about the optimal long-term circulation strategy

Early consultation can be particularly valuable when planning initial palliation, evaluating ventricular growth potential or reconsidering patients previously thought unsuitable for biventricular repair. However, patients with Fontan circulations and BDGs can still be excellent candidates if they have one of the above diagnoses.

Virtual Surgical Planning and Case Collaboration: To Learn more about Cincinnati Children’s VR3S platform, contact ryan.moore@cchmc.org and to discuss a complex case for surgical planning, contact, sassan.hashemi@cchmc.org.

(Published November 2026)

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