Year : 2009 | Volume
: 10 | Issue : 4 | Page : 156--161
A brief review on hybrid procedures in congenital heart disease
Meena Nathan, Rajiv Verma, Duraisamy Balaguru, Joanne Starr
M.D., Children's Heart Center, Children's Hospital of New Jersey at Newark Beth Israel Medical Center, USA
M.D.,Pediatric Cardiac Surgeon,Children’s Heart Center, Children’s Hospital of New Jersey @ NBIMC, Suite L5, Clinical Assistant Professor of Surgery, UMDNJ, 201 Lyons Ave, Newark, NJ 07112
Hybrid approaches to management of complex congenital heart disease is a fast growing field. This is of particular importance in specific defects that cannot be dealt with ease and safety either in the surgical suite or catheterization laboratory because of certain patient and anatomic characteristics. This brief review outlines some of the defects in which a hybrid approach allows surgeons and interventional cardiologist to combine their expertise and provide the best approach to correct or palliate these defects with optimal outcomes.
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Nathan M, Verma R, Balaguru D, Starr J. A brief review on hybrid procedures in congenital heart disease.Heart Views 2009;10:156-161
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Nathan M, Verma R, Balaguru D, Starr J. A brief review on hybrid procedures in congenital heart disease. Heart Views [serial online] 2009 [cited 2020 Jul 13 ];10:156-161
Available from: http://www.heartviews.org/text.asp?2009/10/4/156/63672
Management of complex congenital heart defects in the neonatal period has traditionally been surgical. In recent years, a hybrid approach has been developed, where surgeons and interventional cardiologists combine their expertise in correcting or palliating complex heart defects in neonates, infants and children; that cannot be adequately addressed by surgery or interventional catheterization alone. The purpose of this review is to outline the new hybrid approaches, and elucidate the advantages with the aid of case examples.
The following hybrid procedures will be discussed:
Hybrid Stage I Palliation for hypoplastic left heart syndrome (HLHS)Perventricular device closure of muscular ventricular septal defect (VSD)Intra-operative pulmonary artery rehabilitationPerventricular pulmonary valvotomy for pulmonary atresia intact ventricular septumCarotid cut down for neonatal aortic valvuloplasty
Hybrid Stage I Palliation for Hypoplastic Left Heart Syndrome
Case Report: A five day old 3 kg neonate presented to the emergency room in shock with clinical findings suggestive of necrotizing colitis (NEC). Echocardiogram confirmed hypoplastic left heart syndrome with adequate atrial level communication and a constricted ductus arteriosus. Prostaglandin E1 was initiated, the baby was hemodynamically stabilized, and necrotizing enterocolitis was medically managed. The baby was then taken to the catherization suite and hybrid stage I palliation performed i.e. median sternotomy, branch pulmonary artery (PA) banding with Teflon rings cut from a 3.5mm goretex tube graft, main pulmonary artery puncture and ductal stenting and confirmation angiograms to ensure adequacy of PA bands and ductal stent. The atrial septal communication was adequate, therefore it was not balloon dilated. The post operative period was uneventful and the baby was discharged home after a 2 week hospital stay.
Bacha  et al reported their hybrid stage I experience in 14 high risk neonates and had a hospital survival of 78.5% in this high risk group. Galantowicz  et al reported their intermediate results in 40 patients, 36 of whom have undergone comprehensive stage II procedure and 15 have gone onto fontan completion with a 82.5% overall survival.
Hybrid Stage I palliation avoids neonatal cardiopulmonary bypass and significantly decreases days on the ventilator and hospital length of stay. In patients with significant co-morbidities such as NEC or Intraventricular hemorrhage (IVH), hybrid stage I is a good alternative to standard Norwood palliation. Despite the stage II procedure being more complex , , it has the advantage of being performed in an older and larger infant. In addition use of the hybrid approach for stage I, allows palliation to be completed with two instead of three exposures to cardiopulmonary bypass.
Perventricular device closure of VSD
Case Report: An eight day old 3.6kg infant presented to an outside hospital in extremis. PGE-1 was initiated. Echocardiogram revealed severe coarctation, arch hypoplasia and a hemodynamically significant 8mm muscular VSD. A decision was made to adopt a hybrid approach. In the operating room, under trans-esophageal echocardiogram guidance via a perventricular approach a 10mm Amplatzer Muscular VSD Occluder was deployed. Aortic arch reconstruction was then performed under deep hypothermia and regional low flow perfusion. The patient was discharged home on the eleventh post-operative day after an uneventful course.
Bacha  et al described their multicenter experience with perventricular device closure of muscular VSD's in sixteen patients. Twelve were isolated VSD's, two were associated with coarctation and two had associated complex congenital heart defects. There were no deaths and at median follow up of 12 months all were asymptomatic and two had mild residual shunt.
Perventricular device closure overcomes the difficulty of vascular access and need for use of large caliber sheaths required for percutaneous VSD device deployment. Perventricular device closure significantly shortens the duration of cardiopulmonary bypass and cardiac arrest that would other wise be required for the standard surgical correction of combination of defects such as muscular VSD and arch hypoplasia.
Intraoperative pulmonary artery rehabilitation
Case Report: A 14 year old with tetralogy of Fallot repaired initially with a right modified Blalock Taussig shunt, followed by full repair with a 13mm right ventricle to pulmonary artery conduit at two years of age presented to us with severe conduit stenosis and suprasystemic right ventricular pressures. Additionally the patient had long segment hypoplasia of the right pulmonary artery. Based on catheterization findings a decision was made to adopt a hybrid approach. Intraoperatively after removal of the old conduit, and opening of the native right ventricular outflow tract and resection of obstructing muscle bundle, under cardioscope guidance a Genesis Palmaz XD stent was deployed. Direct placement of stent avoided proximal deployment and allowed pulmonary valve replacement and right ventricular outflow tract reconstruction with an anterior goretex hood without difficulty.
Ungerleider  described intra-operative stenting in a series of 31 procedures in 27 patients of which 22 involved stenting of stenotic pulmonary arteries with excellent short term and long term outcomes and no stent related deaths.
Intra-operative hybrid approach of stenting under cardioscope guidance, avoids compromise of lobar and segmental branches. It allows for significant decrease in cardiopulmonary bypass times and avoids extensive retro and para-aortic dissection with its associated vascular, lymphatic and phrenic nerve injury.
Perventricular pulmonary valvotomy for pulmonary atresia intact ventricular septum
Case Report: A 2.8kg full term male infant was diagnosed with pulmonary atresia, intact septum on echocardiogram performed for cyanosis. Cardiac catheterization performed on day of life 3 demonstrated pulmonary atresia with intact septum, good sized main pulmonary artery and confluent branch pulmonary arteries without antegrade flow across the RVOT. There were normal origins of right and left coronary arteries and no evidence of RV dependent coronary circulation. An attempt was made to perform a balloon pulmonary valvuloplasty but it was not possible to cross the RV outflow tract. The patient was taken to the operating room to relieve this pulmonary atresia with a hybrid intervention. A perventricular balloon pulmonary valvuloplasty and placement of a right modified Blalock-Taussig shunt with patent ductus arteriosus ligation was performed. The patient had an uneventful postoperative course and was discharged home after a two week hospital stay.
Zhang  et al reported 4 cases of this hybrid approach to management of pulmonary atresia intact ventricular septum with excellent short term results.
Hybrid intervention in this case avoided cardiopulmonary bypass that would have been required for surgical pulmonary valvuloplasty. It also allowed for direct access to the pulmonary valve thereby avoiding complications associated with vascular access and guide wire manipulation in a small neonate.
Carotid cutdown for neonatal aortic valvuloplasty
Case Report: A two months old ex 30 weeks, 2.7kg premature female infant was transferred from an outside institution for management of critical aortic stenosis and significant aortic coarctation. The baby was taken to the operating room and a right carotid cut down was performed followed by balloon aortic valvuloplasty under trans-thoracic echo guidance. The baby then underwent a left lateral thoracotomy and extended end to end anastomosis of coarctation and was discharged home after an uneventful postoperative recovery.
Carotid cut down for aortic valvuloplasty was initially described in the 1970's but introduced as a safe alternative by Fischer  and colleagues in 1990. Since then there have been several case series reporting the safety and efficacy of this approach.
Advantages of the hybrid approach in this case avoided a median sternotomy incision and cardiopulmonary bypass that would have been needed to perform aortic valvuloplasty. Performance of carotid cut down allowed for safe direct vascular access and avoidance of trauma to the small femoral vessels. Both procedures were done with same anesthetic and there was a significant decrease in hospital length of stay.
Other hybrid procedures
Hybrid approach can be used for multiple other procedures. It has enabled intraoperative pulmonary vein dilatation for stenosis. Intraoperative balloon dilatation of the pulmonary valve is an alternative to surgical valvotomy during full neonatal repair of tetralogy of Fallot. The perventricular approach has been used for catheter based implantation of pulmonary and aortic valves.[Figure 1],[Figure 2],[Figure 3],[Figure 4],[Figure 5],[Figure 6],[Figure 7]
Hybrid interventions allow for safe repair of complex congenital anomalies in all ages including the neonatal period. Advantages of this approach include:Hybrid stage I palliation allows for safe palliation even in high risk neonates with avoidance of exposure to cardiopulmonary bypass and circulatory arrest in the vulnerable neonatal period.Hybrid approach to muscular VSD overcomes the difficulty of vascular access and need for use of large caliber sheaths required for percutaneous device deployment.It significantly shortens the duration of cardiopulmonary bypass and cardiac arrest which would otherwise be required to address certain combination defects surgically.Intra-operative hybrid approach of stenting pulmonary artery (especially with cardioscope guidance), avoids compromise of lobar and segmental branches.Intra operative stenting allows for significant decrease in cardiopulmonary bypass times and avoids extensive retro and para-aortic dissection with its associated vascular, lymphatic and phrenic nerve injury.Carotid cut down allows direct access to the aortic valve especially in small neonates (As the number and age of survivors with repaired or palliated congenital heart defects increase, there is a corresponding increase in the number of patients in whom vascular access is poor or absent. These patients will definitely benefit from such a hybrid approach.
|1||E A Bacha, S Daves, J Hardin et al. Single-ventricle palliation for high risk neonates: The emergence of an alternative hybrid stage I strategy. J Thorac Cardiovasc Surg. 2006;131:163-71|
|2||M Galantowicz, J P Cheatham, A Phillips et al. Hybrid approach for hypoplastic left heart syndrome: Intermediate results after the learning curve. Ann Thorac Surg. 2008;85:2063-71|
|3||E A Bacha, Q L Cao, M E Galantowicz et al. Multicenter Experience with Perventricular Device Closure of Muscular Ventricular Septal Defects. Pediatric Cardiology 2005;26:169-175|
|4||R Ungerleider, T A Johnston, M P O'Laughlin et al. Intraoperative Stents to Rehabilitate Severely Stenotic Pulmonary Vessels. Ann Thorac Surg 2001;71:476-81|
|5||H Zhang, S Li, Y Li et al. Hybrid procedure for the neonatal management of pulmonary atresia with intact ventricular septum. J Thorac Cardiovasc Surg. 2007; 133:1654-66|
|6||D R Fischer, J A Ettedgui, S C Parks. Carotid approach for balloon dilatation of aortic valve stenosis in the neonate: A preliminary report. J Am Coll Cardiol 1990; 15:1633-36.|