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3–5 years old at the time of palliation is the ideal age for a BDG. This is the period when PVR is lower than when the left ventricle is most compliant. Also during this period, the need to separate systemic from pulmonary blood flow becomes more important. Once the left ventricle achieves high compliance, its function becomes dominant over PVR in determining flow to the pulmonary vasculature. Most deaths after a BDG in this age group occur in the immediate postoperative period, primarily because of arrhythmias related to hypothermia and electrolyte abnormalities. In the intermediate term, it is not unusual for patients to have difficulty with the development of native AV valves. A smaller proportion of these older patients has arrhythmias and/or shunt dysfunction and requires reoperation.

Patients with single ventricle heart disease may undergo a BDG procedure as a definitive repair. With this strategy, the size of the ventricular septal defect (VSD) is enlarged in non-circulated ventricles by perforation of the septum between the arterial and venous poles of the ventricle. When the septum between the left- and right-sided heart becomes incompetent, “mixing” occurs. Mixing refers to the development of mixed systemic and pulmonary circulation through the VSD. After successful repair of the VSD, the pulmonary circuit is purified, and pulmonary blood flow is based on passive intraventricular blood flow.

The principle steps in the BDG procedure are initial systemic hypothermia followed by circulatory arrest and antegrade perfusion and cooling of the systemic blood to 15°C with an interposed antegrade cardioplegia circuit, followed by homologous reperfusion and equilibration of the circulatory system. The BDG includes systemic venous drainage to a separate low-pressure side of the circuit (systemic venous return), which is freed from the systemic venous return via a separate side of the circuit (pulmonary venous return), which is then drained through a side arm of the arterial cardiopulmonary circuit. Careful assessment of both the valve function and cardiac function is essential for ensuring the safe completion of the procedure.

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