Hybrid procedure for the neonatal management of pulmonary atresia with intact ventricular septum

Hybrid Interventions in Congenital Heart Disease: A Review of Current Practice and Rationale for Use

BACKGROUND

Hybrid interventions have become a common option in the management for a variety of patients with congenital heart disease. In this review, we discuss the data that have driven decision making about hybrid interventions to date.

METHODS

The existing literature on various hybrid approaches was reviewed and summarized. In addition, the key tenants to creating a successful hybrid program within a congenital heart center are elucidated.

RESULTS

Hybrid strategies for single-ventricle patients, pulmonary atresia with intact ventricular septum, branch pulmonary artery stenosis, and muscular ventricular septal defect closure have important benefits and limitations compared with traditional approaches.

CONCLUSION

A growing body of evidence supports the use of hybrid interventions in congenital heart disease. But important questions remain regarding improved survival and other long-term outcomes, such as neurocognition, that might impact widespread adoption as a primary treatment strategy.

Hybrid Subxiphoid Perventricular Approach as an Alternative Access in Neonates and Small Children Undergoing Complex Congenital Heart Interventions

The hybrid subxiphoid perventricular approach provides direct access through the heart and may alleviate the technical limitations of complex percutaneous interventions particularly in infants with low body weight. We present the outcomes from a tertiary cardiology center using this approach. We performed a retrospective review of all patients less than 15 kg who underwent a hybrid perventricular approach via a small subxiphoid incision. Medical records were reviewed to obtain clinical, demographic and outcome data. Seventeen patients underwent 18 hybrid perventricular procedures using a subxiphoid approach. Median age at time of procedure was 4.6 months (IQR = 1.6 to 18 months) and median weight was 6.2 kgs (IQR = 3.4 to 8.6 kgs). Six patients underwent hybrid pulmonary valve replacement (PVR), 5 patients underwent pulmonary outflow stenting, and 5 infants underwent hybrid ventricular septal defect (VSD) device closure. One patient with a single ventricle who did not tolerate a percutaneous approach underwent left pulmonary artery (LPA) stenting for severe LPA coarctation with subsequent right ventricular outflow tract (RVOT) stenting. One further patient underwent implantation of a larger diameter stent for pulmonary artery bifurcation stenosis. Procedure success rate was 89% with two of the VSD cases reverted to open surgical repair. There were no intra-procedural complications; however, one patient died within 72 h. Minor adverse events occurred in 2 patients including a wound infection in one patient with an immunodeficiency syndrome. Hybrid subxiphoid perventricular approach provides an excellent alternative access to the heart especially in low birth weight infants to prevent hemodynamic instability or in small children requiring large delivery sheaths.

Innovative interventional catheterization techniques for congenital heart disease

Since 1929, when the first cardiac catheterization was safely performed in a human by Dr. Werner Forssmann (on himself), there has been a rapid progression of cardiac catheterization techniques and technologies. Today, these advances allow us to treat a wide variety of patients with congenital heart disease using minimally invasive techniques; from fetus to infants to adults, and from simple to complex congenital cardiac lesions. In this article, we will explore some of the exciting advances in cardiac catheterization for the treatment of congenital heart disease, including transcatheter valve implantation, hybrid procedures, biodegradable technologies, and magnetic resonance imaging (MRI)-guided catheterization. Additionally, we will discuss innovations in imaging in the catheterization laboratory, including 3D rotational angiography (3DRA), fusion imaging, and 3D printing, which help to make innovative interventional approaches possible.

Transthoracic Balloon Pulmonary Valvuloplasty for Treatment of Congenial Pulmonary Atresia Patients with Intact Ventricular Septum

Background

To summarize our clinical experience in performing transthoracic balloon pulmonary valvuloplasty for the treatment of patients suffering from congenial pulmonary atresia with intact ventricular septum (PA/IVS).

Material/Methods

Between April 2009 and April 2016, 38 patients with PA/IVS underwent transthoracic balloon pulmonary valvuloplasty in our hospital. All of them were combined with patent ductus arteriosus, tricuspid insufficiency, and atrial septal defect or patent foramen ovale. The valvuloplasty was performed from the right ventricular outflow tract through a median sternotomy incision under TEE guidance for all cases.

Result

Thirty-five patients were successfully discharged, and 3 patients died after the operation. The 35 surviving patients were followed up. Spo2 in the 35 patients was 88–96% after the operation. The transpulmonary valvular gradient pressure was less than or equal to 30 mmHg in 31 patients and between 36 and 52 mmHg in the other 4 patients. After the surgery, tricuspid regurgitation was significantly reduced. We found only 4 patients with moderate regurgitation, 5 patients with mild to moderate regurgitation, and mild regurgitation in the remaining 26 patients. Five patients underwent a second-stage operation, including biventricular repair in 4 patients and ligation of ductus arteriosus in 1 patient.

Conclusions

The application of transthoracic balloon pulmonary valvuloplasty for the treatment of PA/IVS is minimally invasive and safe, which has great significance for improving the curative effect for this condition and reducing operation mortality.

Popular Hybrid Congenital Heart Procedures without Cardiopulmonary Bypass

As surgical and catheter interventions advance, patients with congenital heart disease are now offered alternative treatment options that cater to their individual needs. Furthermore, collaboration between interventional cardiologists and cardiac surgeons have led to the development of hybrid procedures, using the best techniques of each respective field to treat these complex cardiac entities from initial treatment in the pediatric patient to repeat intervention in the adult. We present a review of the increased popularity and trend in hybrid procedures in congenital heart disease without the use of cardiopulmonary bypass.

From atretic to perforated: a closer view of pulmonary atresia

A 7-day-old male infant with membranous pulmonary atresia and intact ventricular septum (PA/IVS) underwent hybrid pulmonary valvotomy. Access was via median sternotomy guided by intra-operative epicardial ultrasonography. After puncturing the atretic pulmonary valve, a 6 mm Wanda balloon catheter was inflated to dilate the atretic valve. Adequate valve movement with antegrade flow was confirmed using real time epicardial echocardiography. Intra-operative epicardial ultrasonography is an effective tool for guiding PA/IVS during hybrid procedures. Epicardial echo imaging provides clear images with excellent quality, helps guide the hybrid operation, and prevents the need for the ionizing radiation of fluoroscopy.

Hybrid procedure for pulmonary atresia with ventricular septal defect in a low birth weight neonate

Cardiac surgery in neonates with congenital heart disease has progressed dramatically in the past three decades. However, low-birth-weight neonates with congenital heart disease continue to challenge the intellectual and technical skills of healthcare professionals. We present a case of a low-birth-weight neonate with pulmonary atresia and a ventricular septal defect, in whom palliation was achieved with a right ventricular outflow tract stent using a hybrid procedure.

Catheter-based therapy for small preterm infants with pulmonary atresia/intact ventricular septum

Catheter-based therapy is the preferred treatment for term infants with pulmonary atresia and intact ventricular septum without right ventricular-dependent coronaries, membranous atresia with patent infundibulum, and acceptable-sized tricuspid valve. However, in smaller preterm infants, it is more difficult to determine the adequacy of the tricuspid valve and right ventricle for two-ventricle repair and there are increased procedural risks. An excellent result in a small preterm infant with pulmonary atresia and intact ventricular septum is described using the following algorithm: determination of the tricuspid/mitral annular ratio, right-sided catheter-based intervention, and a combination of transthoracic echocardiography and angiography.

Minimal incision congenital cardiac surgery

Minimally invasive techniques have had limited application in congenital cardiac surgery, primarily due to the complexity of the defects, small working area, and the fact that most defects require exposure to intracardiac structures. Advances in cannula design and instrumentation have allowed application of minimal incision techniques but in most cases, cardiopulmonary bypass is still required. Image guided surgery, which uses noninvasive imaging to guide intracardiac procedures, holds the promise of permitting performance of reconstructive surgery in the beating heart in children.