Redefining Biventricular Repair Feasibility in Prenatal Counseling: A Review of Fetal Echocardiograms in Patients Selected for Complex Biventricular Repair.

Surgical advances have recently expanded the boundaries of feasibility for biventricular repair (BVR) in patients with complex congenital heart disease (CHD). In particular, diagnoses historically considered prohibitive for BVR-such as unbalanced atrioventricular septal defects (uAVSD), double-outlet right ventricles (DORV) with remote ventricular septal defects (VSD), atrioventricular valve straddle (AVVS), and heterotaxy-are now increasingly being managed with successful two-ventricle strategies. To determine whether fetal echocardiographic features once viewed as contraindications to BVR remain valid in the current surgical era, we retrospectively reviewed all patients evaluated by our institutional BVR committee from June 2023 to February 2025 with prenatally diagnosed uAVSD, DORV, or DORV-AVSD. Among the 23 patients selected for BVR, 16 had available fetal echocardiograms. Features historically associated with poor BVR candidacy were common, including RV outflow tract obstruction (56%), ventricular hypoplasia (44%), heterotaxy (25%), AVVS (13%), remote VSDs (25%), and pulmonary venous anomalies (19%). Despite these findings, all patients were managed with BVR strategies, with the majority achieving complete or staged biventricular circulation at the time of publication. Notably, patients deemed unsuitable for BVR were significantly older at time of referral, highlighting the potential role of fetal cardiology in early identification and timely referral. These findings suggest that many prenatal features long considered exclusionary are no longer barriers to BVR, underscoring the need to modernize fetal counseling frameworks, reflecting contemporary surgical capabilities. As the landscape evolves, fetal cardiologists must adapt their counseling strategies to offer families accurate prognostic information and renewed hope.