Single Ventricle Alphabet Soup

When we first learned Luna’s heart was composed of just one ventricle, the only information I could find on her rare anatomical condition was for Hypoplastic Left Heart Syndrome (HLHS). Because of her unusual heart, bi-weekly echocardiograms at Children’s Boston became part of our regular pre-natal care. And each appointment, where I would sit in a darkened room for close to an hour and a half, while the cardiologist circumferenced my globe-like belly with a forceful probe; I would ask him, “but this baby doesn’t have HLHS?” Kindly, patiently, Dr. Brown would answer my anxious and continuous inquiries the same way each time: “No, this baby’s heart does not fall into the HLHS category of single ventricle formation.”

A recent blog post brought in several comments, many from other heart moms commiserating with me; welcoming us to their pack, Luna is HLHS too, they cheered.

But actually, Luna is not HLHS; she falls into her own unique category for single ventricle kids. Her own acronym still somewhat up for debate, but most professionals have settled on DORV/DIRV-or Double Outlet Right Ventricle/Double Inlet Right Ventricle.

I decided to ask Luna's New Hampshire cardiologist, Dr. Gauthier (Luna has two cards, one in Boston, and one closer to us in NH) for, oh, about the twelfth time how Luna differs from the HLHS kids. One of Dr. Gauthier’s biggest gifts to her patients (or in our case, to the parents of her patients) is her ability to craft the complicated and complex world of the various Congenital Heart Diseases into easily understood metaphors.

This is what she wrote:

“Luna best fits into a ‘single ventricle’ category. This is what it sounds like- for all intents and purposes, she did not divide her heart into two ventricles, and instead of one or the other ventricle being hypoplastic (small), she only formed one (her right), with both internal valves (mitral and tricuspid) entering into this chamber, and both outlets (aorta and pulmonary artery) arising from this chamber-- that is, it would have, if she had formed two outlets. Instead, she formed only one outlet valve, the aortic valve, and the other, the pulmonary valve, was "atretic"- like a door sealed shut- in her case, so poorly formed that it could not be pried open in any way (which can be done in some cases) but instead they had to find a way to surgically bypass this. So she fits into the "double inlet, doublet outlet right ventricle" category complicated by "pulmonary atresia.". This translates to a single ventricle accepting all inflow and pumping all outflow. To make things more complex, her heart formed pointing rightward instead of the normal leftward location, so she has "dextrocardia." And then last, her aortic valve did form, but instead of forming three leaflets, she has only two leaflets opening and shutting. This is the "bicuspid valve". The only significance to this at this stage is that it makes a little clicky sound when it opens but otherwise it works just fine.

HLHS and HRHS are different anatomically and the importance between those two as well as Luna's "single ventricle" version is in the way it is repaired and how much work has to be done to get the blood to flow out to the body. Luna is on the better end of the spectrum compared to HLHS on that front, although similar in that she really only has a right ventricle doing all the work to pump to her body. HRHS has the advantage in that the ventricle that does the pumping is a left ventricle, which is better designed for that purpose, but all three only use one ventricle to pump to the body and the blood is re-routed surgically to drain passively into the lungs (in other words, all three usually wind up with a version of a Fontan, but with varying types of surgery to get the blood to flow to the body and to the lungs).”

Luna turns two!

Luna surprises herself by successfully blowing out her candles.


On March 11th at 5:23pm, Luna turned two-years old. Luna shares her birthday with Rupert Murdoch (that just makes me laugh...Murdoch, the owner of Fox Network, is naturally considered the most evil figure among Progressives-the irony that our little Lu shares his birthday is not lost).

But some other interesting people share her birthday too. Like the guy who wrote the Hitchhiker's Guide to the Galaxy series, along with Ezra Jack Keats; author and illustrator one of my favorite children's books; A Snowy Day; the first children's book with an urban setting. It's interesting to note that all three of these March 11th personalities are connected the world of publishing.

Luna and I spent her special day together, shopping and doing lunch-alone-while Sienna played at school. In the morning we had her two-year wellness appointment. Dr. Goodnews did the usual ears, mouth, heart routine. Everything looked great. It had been a while since anyone had listened to Luna's heart, so I was holding my breath. While the pediatrician was listening to her, in his smiling-casual-everything-is-rosy-kind-of-way, told me he heard a 'click' in Luna's chest. I'm fairly used to clicks and clanks, and other strange noises doctors glean from pressing a stethoscope against Luna's tiny chest. When I asked Luna's cardiologist later what this meant she responded saying, "rather than a tricuspid valve, Luna's has a bicuspid valve, and the click is a result of that anomaly and means nothing more than if she was a blonde, or redhead or brunette." (For a good, simple set of drawings showing the difference between a tricuspid valve, or normal aortic valve, and a bicuspid valve , click here.)

Luna still walks with a young toddler 'toddle', so we wanted to have the doctor check that out as well. Actually, a better description of Luna's gait would be 'waddle'; which like most things, is adorable at two, and becomes not-so-adorable fairly quickly; like by the age of three. Dr. Goodnews had Luna waddle down the hall and assessed immediately that her toddle-waddle is nothing more than a result of her being a late walker (18 months).

Finally, Luna was measured and weighed. She tips the scale at 25 lbs exactly, measuring 33 1/2 inches tall. She's in the 25 percentile for both, which is just perfect for Lu, and where she's been all along. (Nothing wrong with being petite I say!)

Our appointment ended with an assessment of Luna's verbal skills. Dr. Goodnews asked me how Luna's speech was doing. I explained to him that she's not as verbose as her sister was at this age (seriously thank God, I'm not sure I could handle two kids talking on the level as Sienna).

Dr. Goodnews grilled me on the "does she say this?" series of questions, so I offered the doctor the following dialog that had recently occurred between the girls:

Luna: "Nanu WORK in RESTAURANT!"

Sienna: "Noooooo Looooona, you're too small!"

Luna: "Nanu can work in RESTAURANT!"

Sienna: "Nooooo Loooona, they won't let you! You're too little".

(continue dialog for 20 minutes until both girls spill over into shrieks and cries.)

Dr. Goodnews seemed pleased with this exchange, and just nodded his head and said, "She's right on track."

Fundraiser for Luna

A few friends have brought up the idea of having a fundraiser for Luna. The idea inspired, frightened and humbled me all at once. I wasn't sure if I was supposed to get the ball rolling on such a lofty undertaking. But before I could even give it much thought the very generous owner of Gymboree Music & Play in Rye, NH has offered, through Seacoast Mother's Association, to organize one herself.

Her name is Marlow Rahn, and just about anyone who has young kids on the New Hampshire Seacoast, and has brought their kids to Gymboree, knows Marlow.

I'll let her put into words what she plans to do, but for now she asked me to write-up a third person account of Luna's heart defects along with the level of care, surgeries she has undergone and will undergo; and subsequent cost of it all.

The fundraiser will run starting the month of April, which is significant since it will be the beginning of Luna's journey through her open heart surgery.

Marlow has asked me to include a selection of photos as well, starting with her birth, including some post-surgery shots, and of course some fun ones depicting our chubby-cheeked sweetness in all her glory. (the photos are chronologically backwards, starting with the most recent first...scroll down to see her first days of life)

So, for those of you who have been following her story since her birth, this will be a recap; and for those of you just learning about the amazing Lu, this will be a nice introduction.
#############################################################

In October of 2007 while just 20 weeks gestational age, Luna’s parents learned the baby they were carrying had a series of rare heart defects. In utero it was difficult-because of the complicated nature of her anatomy-for the doctors to determine exactly what they were. But it was known that she had a single ventricle, enlarged aortic artery, either pulmonary astresia or stenosis, and finally dextrocardia, the condition that made it so challenging for doctor's to decipher her heart; an otherwise harmless condition in which the heart is rotated mirror image from what it should be, and located on the right side of the chest (rather than, of course the left, where most human hearts sit).

Luna's parents were given the choice to either terminate the pregnancy at 21 weeks, or continue with the birth and ensuing three operations that would ultimately reroute her blood flow and keep her alive.

On March 11, 2008 Luna was born, otherwise completely healthy and weighing in at 7 lbs even. On her second day of life she underwent open heart surgery to install the BT shunt-and fared exceptionally well. Not a week after surgery, baby Luna was discharged from the hospital and sent home.

At 6 months of age Luna underwent the Glenn operation-a surgery in which the superior vena cava is rerouted into the right branch of the pulmonary artery; giving the overworked single ventricle a break (since esentially the lone chamber must do the work of the missing half).

After two cardiac catheters (both with angioplasty-to enlarge her left pulmonary artery that had significantly narrowed) and countless echo cardiograms, it was determined by Luna's medical team that she has one single ventricle. Her cardiologist, Dr. Gauthier describes best her condition here:

in these complicated cases, it can be hard to tell whether it is a single right or a single left one. Luna is felt to have a single right ventricle. She also has a double inlet- both "AV valves" or inlets into her ventricle enter into the one single chamber, giving her "Double Inlet Right Ventricle", even more rare than Double Inlet Left Ventricle (DILV). Along with dextrocardia- heart in the right side of her chest instead of left- she also has transposed great arteries, meaning the aorta is in front of her pulmonary instead of behind. However, many single ventricle kids have pulmonary stenosis, but she goes beyond "pulmonary stenosis" (pulmonary valve has a very narrowed opening) to what she has, "pulmonary atresia" (valve not open at all, or never formed). Luna will undergo the same surgeries as many other single ventricle kids to re-route blood flow.

Starting next month Luna will undergo more procedures to determine when she will go in for her final and last repair, the Fontan surgery. In layman terms the operation is really, really sophisticated plumbing. Before Luna is operated on she will under-go a sedated echocardiogram and a catheter. Both are exploratory, so her surgeons will know exactly what to expect come the big day.


The cost for these sophisticated surgeries can run a couple hundred thousand dollars each. Most heart kids hit the million or 2 million dollar cap on their lifetime insurance by the time they reach five years old. And Luna is no different. While the family has insurance, budgeting and planning for her care is a moving target. The family's 2010 insurance rates doubled from the year before, mostly because so many claims were placed for Luna's care.

The total family burden for Luna's 2010 care is projected over $20,000. This is before denied claims or out of network issues take affect, which could easily double that amount.

One of the more costly medical needs Luna has is her Synagis shot. During the RSV season, heart babies, young children with upcoming surgeries, and other immune compromised infants and toddlers must get an injection every 30 days to stave off the potentially deadly respiratory disease. The cost for the shot depends upon the child’s weight, and ranges from $2000 to $3700 per shot. Only a few pharmacies in the country administer the inoculation, and all require full payment up front before they will ship the medicine.