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Cardiology
Hybrid Procedures in Congenital Heart Disease
a report by
Stefano Di Bernardo,
1
Michel Hurni
2
and Marie-Hélène Perez
3
1. Paediatric Catheterisation Laboratory, Department of Paediatrics; 2. Department of Cardiovascular Surgery; 3. Intensive Care Unit, Department of Paediatrics,
University Hospital and University of Lausanne
Surgery and interventional cardiology have developed greatly during the arteries. The second step, Norwood stage II, is a bidirectional Glenn
last decades. For any congenital heart disease a surgical procedure is anastomosis. The third step is the completion of a Fontan circulation, with
possible to obtain complete correction or acceptable palliation. Progress in a connection between inferior vena cava and pulmonary arteries.
interventional cardiology opens up new directions for the treatment of
simple heart defects. Today many simple lesions are suitable for correction HLHS is a typical congenital cardiac malformation with the first surgical
in the catheterisation laboratory. Since the beginning of this century long- palliation occurring in the first days after birth, in which high surgical
term follow-up studies and developmental surveys have been published.
1-3
mortality and high long-term morbidity have been reported. Some authors
Paediatric patients with congenital heart disease, particularly those who have demonstrated a striking association for these infants between
need an intervention in the perinatal period or repeated surgeries, duration of deep hypothermic circulatory arrest performed during this
demonstrate different kinds of disability at school age. Although surgical procedure and developmental outcome at school age.
1
cardiopulmonary bypass is a huge advance, it also has detrimental effects.
In an attempt to change the traditional surgical strategy, hybrid therapy
Confronted with these observations, new strategies have been developed combines stent implantation in the ductus arteriosus by the interventional
to shorten cardiopulmonary bypass or to avoid particularly risky surgical cardiologist and a surgical band for both pulmonary arteries, in order to
approaches. These new strategies are called hybrid procedures because maintain systemic perfusion and restrict pulmonary blood flow to the
they emerge from the collaborative efforts of cardiac surgeons and lungs. Usually, this procedure is completed with a unique step through a
interventional cardiologists in an approach to managing congenital heart median sternotomy without the need for cardiopulmonary bypass.
6,7
A
disease. The idea is to develop therapies that offer the advantages of few months later, with a larger infant, a comprehensive stage I and II
surgery and interventional techniques in the same setting.
4,5
Norwood is performed. The main advantage of this technique is to
postpone the Norwood I procedure to a later age, allowing a decreasing
Hybrid therapy is not a simple first step. It is a change in approach for global risk of this surgical procedure in the neonatal period and avoiding
surgeons and cardiologists. Both have to admit that joining the two deep hypothermic circulatory arrest. Reconstruction of the aortic arch is
techniques would possibly allow better immediate and long-term results. then carried out in a larger infant, with a probable decreased risk of brain
It also means that cardiologists can enter the operating theatre for other insult than in the neonatal period. The second advantage is to reduce the
reasons than only to look at the transoesophageal echocardiography number of interventions with cardiopulmonary bypass.
(TEE) and that surgeons can enter the catheterisation laboratory not only
for emergency purposes. In other words, surgeons and cardiologists have As for any new surgical or interventional procedure there is a learning curve.
to discuss and collaborate in a positive fashion. Initial problems have been identified and can be overcome. For example,
tightening of the pulmonary bands (too tight or too loose) and stenting of
Indications for hybrid therapy are expanding, the most frequent being the ductus arteriosus when aortic coarctation is present have been
intraoperative stenting, perventricular ventricular septal defect (VSD) addressed as a result of published expertise from leading centres.
8
Although
closure, occlusion of vascular structures during surgical repair and long-term follow-up data are still not known, short- and medium-term
percutaneous palliation for single ventricle physiology (such as follow-up is impressive and comparable to surgical results.
7,9–12
hypoplastic left heart syndrome [HLHS]). Ideally, these interventions are
carried out in a hybrid suite where operating room and catheterisation Avoiding cardiopulmonary bypass with hybrid therapy does not mean
laboratory facilities are brought together. that these patients are less prone to interstage problems and mortality.
Indications, Techniques and Experience
Stefano Di Bernardo is a Paediatric Cardiologist in the Department of Paediatrics of the
University Hospital at the University of Lausanne, Switzerland, where he has been Head of the
Hypoplastic Left Heart Syndrome
Congenital Catheterisation Laboratory since 2003 and in charge of the development of a
HLHS associates hypoplastic left ventricle (unsuitable for systemic hybrid therapy programme for congenital heart disease. Dr Di Bernardo is a member of the
perfusion), aortic valve stenosis and hypoplasia of the ascending aorta.
Swiss Society of Paediatric Cardiology, the Swiss Society of Cardiology, the Association for
European Paediatric Cardiology (AEPC) and the Working Group on Interventional Cardiology
Since the 1980s a three-step surgical palliation can be proposed for these
of the AEPC. Following his paediatrics training at the University Hospital of Lausanne, he
infants. The first step is Norwood stage I, whereby reconstruction of the undertook further training in paediatric cardiology and particularly in interventional cardiology
aortic arch with anastomosis to the pulmonary trunk is performed. At the
in the Children’s Hospital of Zurich.
same time pulmonary blood flow is provided with a modified Blalock-
E: stefano.di-bernardo@chuv.ci
Taussig shunt or a shunt between the right ventricle and pulmonary
© TOUCH BRIEFINGS 2008 11
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