New Therapeutic Avenues with Hybrid Pediatric Cardiac Surgery
DOI:
https://doi.org/10.1532/hsf.804Abstract
Background: Minimally invasive strategies can be expanded by combining standard surgical and interventional techniques.
Methods: A longitudinal prospective study was conducted of all pediatric patients who have undergone hybrid cardiac surgery at the University of Chicago Children's Hospital. Hybrid cardiac surgery was defined as combined catheter-based and surgical interventions in either one surgical setting or planned sequential surgical settings within a 24-hour period.
Results: Between June 2000 and June 2003, 24 patients were treated with hybrid approaches. Sixteen patients with muscular ventricular septal defects (VSDs) with a mean age of 4 months (range, 2 weeks to 4 years) underwent either sequential Amplatzer device closure in the catheterization laboratory followed by surgical completion (group 1A [n = 9]: right ventricular (RV) outflow tract enlargement, 6 patients; closure of other VSDs, 5 patients; tricuspid valvuloplasty, 3 patients; bidirectional Glenn shunt, 1 patient; Maze procedure, 1 patient; and retrieval of embolized device, 1 patient) or, more recently, a 1-stage intraoperative off-pump device closure (group 1B; n = 7) with the subsequent repair of concomitant heart lesions in 5 patients (double-outlet RV, 2 patients; arch hypoplasia/coarctation of the aorta, 2 patients; and pulmonary artery (PA) debanding, 1 patient). Cardioplegic arrest was either avoided or shortened in the muscular VSD patients. Eight patients with branch PA stenoses (group 2) underwent intraoperative PA stenting or stent balloon dilation along with RV outflow procedure (5 patients) or Fontan completion (3 patients with Maze procedure, mitral valvuloplasty, or Damus-Kaye-Stansel procedure in 1 patient each). All patients survived hospitalization. Complications from the hybrid approach in group 1A patients included tricuspid regurgitation in 2 patients, RV disk malposition in 1 patient, embolization of a VSD device into the aorta in 1 patient, and a residual VSD in 1 patient. No complications from the hybrid approach occurred in group 1B patients, and PA rupture from stent overinflation and ventricular dysfunction occurred in 1 patient each in group 2. During a mean followup period of 18 months (range, 2-36 months), 2 group 1A patients died suddenly several months after discharge. All of the other patients are doing well.
Conclusions: Hybrid pediatric cardiac surgery performed in tandem by surgeons and cardiologists is a safe and effective means of reducing or eliminating cardiopulmonary bypass. Patients with muscular VSDs who are small, have poor vascular access, or have concomitant cardiac lesions are currently treated in one setting with the perventricular approach.
References
Amin Z, Gu X, Berry JM, Gidding T, Rocchini AL. 1999. Perventricular closure of ventricular septal defects without cardiopulmonary bypass. Ann Thorac Surg 68:149-54.nAoki M, Forbess JM, Jonas RA, Mayer JE Jr, Castaneda AR. 1994. Results of biventricular repair for double-outlet right ventricle. J Thorac Cardiovasc Surg 107:338-50.nBacha EA, Cao QL, Starr JP, et al. Perventricular device closure of muscular ventricular septal defects on the beating heart: technique and results. J Thorac Cardiovasc Surg. In press.nBhati BS, Nandakumaran CP, Shatapathy P, John S, Cherian G. 1972. Closure of patent ductus arteriosus during open-heart surgery: surgical experience with different techniques. J Thorac Cardiovasc Surg 63:820-6.nChaturvedi RR, Shore DF, Yacoub M, Redington AN. 1996. Intraoperative apical ventricular septal defect closure using a modified Rashkind double umbrella. Heart 76:367-9.nChitwood WR, Gulielmos V. 2003. What is minimally invasive cardiac surgery? [editors' note]. CTSNet. March, 2003. Available at: http://www. ctsnet.org/doc/7525. Accessed October 27, 2003.nFishberger SB, Bridges ND, Keane JF, et al. 1993. Congenital heart disease: intraoperative device closure of ventricular septal defects. Circulation 88:II-205-9.nHjortdal VE, Redington AN, de Leval MR, Tsang VT. 2002. Hybrid approaches to complex congenital cardiac surgery. Eur J Cardiothorac Surg 22:885-90.nHussain A, al Faraidi Y, Abdulhamed J, Bacha EA, Hammer GB, Feinstein JB. 2002. Transesophageal echocardiography-guided transventricular balloon dilation of congenital critical aortic stenosis in the neonate and young infant. J Cardiothorac Vasc Anesth 16:766-72.nKitagawa T, Durham LA, Mosca RS, Bove EL. 1998. Techniques and results in the management of multiple ventricular septal defects. J Thorac Cardiovasc Surg 115:848-56.nKleinert S, Sano T, Weintraub RG, Mee RBB, Karl TR, Wilkinson JL. 1997. Anatomic features and surgical strategies in double-outlet right ventricle. Circulation 96:1233-9.nMendelsohn AM, Bove EL, Lupinetti FM, et al. 1993. Intraoperative and percutaneous stenting of congenital pulmonary artery and vein stenosis. Circulation 88:II-210-7.nOkubo M, Benson LN, Nykanen D, et al. 2001. Outcomes of intraoperative device closure of muscular ventricular septal defects. Ann Thorac Surg 72:416-23.nPetrossian E, Thompson LD, Hanley FL. 2000. Extracardiac conduit variation of the Fontan procedure. Adv Card Surg 12:175-98.nSeddio F, Reddy VM, McElhinney DB, Tworetzky W, Silverman NH, Hanley FL. 1999. Multiple ventricular septal defects: how and when should they be repaired? J Thorac Cardiovasc Surg 117:134-40.nSerraf A, Lacour-Gayet F, Bruniaux J, et al. 1992. Surgical management of isolated multiple ventricular septal defects: logical approach in 130 cases. J Thorac Cardiovasc Surg 103:437-42.nUngerleider RM, Johnston TA, O'Laughlin MP, Jaggers JJ, Gaskin PR. 2001. Intraoperative stents to rehabilitate severely stenotic pulmonary vessels. Ann Thorac Surg 71:476-81.nWaight DJ, Bacha EA, Kahana M, Cao QL, Heitschmidt M, Hijazi ZM. 2002. Catheter therapy of Swiss cheese ventricular septal defects using the Amplatzer muscular VSD occluder. Catheter Cardiovasc Interv 55:355-61.n
