Hybrid cardiovascular procedures in the treatment of selected congenital heart disease in children: a single-centre experience
TL;DR: Results of hybrid treatment in children with congenital heart disease in this centre in 2008-2013 encourage further development of these methods and strategies to provide optimal benefits for the patients.
Abstract: Wstep: Mimo ciąglego postepu w zakresie technik diagnostycznych i terapeutycznych w ostatnich latach brakuje istotnego postepu w leczeniu wrodzonych wad serca. Czynione są intensywne wysilki w kierunku doskonalenia kardiochirurgicznych technik operacyjnych oraz interwencji kardiologicznych, a takze lączenia ich w celu uzyskania lepszego wyniku terapii. Zabiegi hybrydowe w leczeniu wrodzonych wad serca u dzieci zyskują coraz wiekszą popularnośc, rozszerza sie zakres wad serca leczonych w ten sposob oraz populacja pacjentow mogących byc beneficjentami terapii hybrydowej. Wspolcześnie procedury hybrydowe stosuje sie w sytuacjach, gdy rutynowe zabiegi kardiochirurgiczne lub przezskorne zabiegi interwencyjne nie przynioslyby zadowalającego efektu terapeutycznego. Cel: Celem pracy bylo przedstawienie wlasnych doświadczen ośrodka we wdrazaniu i praktycznym zastosowaniu procedur hybrydowych w leczeniu wybranych wrodzonych wad serca u dzieci w latach 2008–2013. Metody: Retrospektywnej analizie poddano wlasny material stanowiący grupe 80 pacjentow kwalifikowanych do procedur hybrydowych, wykonanych na Oddziale Kardiochirurgii Dzieciecej PCT w Gdansku. Wyniki: Wśrod prezentowanej grupy 80 pacjentow zyje 73 dzieci; zanotowano 4 zgony wczesne i 3 poźne. Wnioski: Zabiegi hybrydowe u dzieci z wrodzonymi wadami serca lączą doświadczenia kardiochirurgii oraz kardiologii interwencyjneji stanowią dodatkową opcje terapii dla wybranej grupy pacjentow. Wstepne wyniki leczenia hybrydowego są zachetą do dalszego rozwoju opisywanych metod i wypracowywania strategii w celu osiągniecia optymalnej korzyści dla pacjenta.
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TL;DR: The results suggest that the hybrid procedure is associated with worse early survival compared to the traditional Norwood when used for initial palliation of infants with hypoplastic left heart syndrome.
Abstract: The hybrid strategy is an alternative to the traditional Norwood procedure for initial palliation of infants with hypoplastic left heart syndrome (HLHS) who are deemed to be at high surgical risk. Numerous single-center studies have compared the two procedures, showing similar early outcomes, although the cohort sizes are likely insufficiently powered to detect significant differences. The current meta-analysis aims to explore the early morbidity and mortality associated with the hybrid compared to the Norwood procedure. MEDLINE, Cochrane Libraries, and Embase were systematically searched, and 14 studies were included for statistical synthesis, comprising 263 hybrid and 426 Norwood patients. Early mortality was significantly higher in the hybrid patients (relative risk [RR] = 1.54, P .05, 95% CI: 0.46-1.70). Six-month (RR = 0.89, P < .05, 95% CI: 0.80-1.00) and one-year (RR = 0.88, P < .05, 95% CI: 0.78-1.00) transplant-free survival was also inferior among the hybrid patients. Furthermore, the hybrid patients required more reinterventions following initial surgical palliation (RR = 1.48, P < .05, 95% CI: 1.09-2.01), although the two groups had comparable length of hospital and intensive care unit stay postoperatively. In conclusion, our results suggest that the hybrid procedure is associated with worse early survival compared to the traditional Norwood when used for initial palliation of infants with HLHS. However, due to the hybrid being used preferentially for high-risk patients, definitive conclusions regarding the efficacy of the procedure cannot be drawn.
15 citations
30 Nov 2014
TL;DR: The CCR-GUCH program appears to be a justified supplement to holistic care in the late rehabilitation of patients after the surgical correction of congenital heart defects.
Abstract: Introduction: The group of grown-up patients with congenital heart defects (grown-up congenital heart – GUCH) complains of a number of specific medical and non-medical problems. The presented program of comprehensive cardiac rehabilitation (CCR-GUCH), dedicated to the above mentioned group, can potentially improve the physical activity of GUCH patients. Aim: The aim of the study was to assess the effect of the comprehensive cardiac rehabilitation program on the physical activity of GUCH patients. Material and methods: The invitation to take part in the CCR-GUCH program was addressed to a group of 57 patients (mean age: 23.7 ± 4.1 years) who had undergone the surgical correction of ventricular septal defects (VSD) or atrial septal defects (ASD) at least 12 months earlier. The pa tients were divided into two groups: A – patients undergoing rehabilitation, and B – patients who did not participate in the program. The patients were initially examined using functional and stress tests, and the program of comprehensive cardiac rehabilitation was started in group A. After 30 days, the patients from both groups underwent further testing using the same methods as during the initial evaluation. Results: After one month of rehabilitation, the physical activity parameters of patients participating in the CCR-GUCH program (group A) were significantly better than those observed among non-participants (group B). Conclusions: The introduction of the comprehensive rehabilitation program improves the physical activity and, consequently, the quality of life of GUCH patients. The CCR-GUCH program appears to be a justified supplement to holistic care
5 citations
TL;DR: The AHASIT of pediatric congenital heart defects with complex and non-cardiac problems appeared to be an attractive option for selected severely ill patients and the strategy was found to be effective in selected neonates suffering from complex and accompanying non-Cardiac pathologies.
Abstract: Introduction: An individually designed strategy of comprehensive alternative hybrid and staged interventional treat- ment (AHASIT) can be a reasonable alternative to conventional treatment of congenital heart defects, reduce the risk of cardiac surgery or interventions performed separately, and give an additional chance for critically ill children. Aim: To present our experience and the results of AHASIT of severely ill or borderline children referred for surgery with the diagnosis of congenital heart defects. Material and methods: A group of 22 patients with complex cardiac and non-cardiac pathologies was retrospectively selected and analyzed. An individual preoperative severity scale was established for AHASIT patients, with one point for each of the following preoperative complications: prematurity, low body weight, cyanosis, intolerance to drug therapy, failed interventional treatment prior to admission, mechanical ventilation prior to the procedure, chronic re- spiratory failure and non-cardiac, mainly congenital malformations (congenital diaphragmatic hernia, lower extremity agenesia, duodenal atresia) and acquired problems (newborn edema, necrotic enterocolitis, intracranial hemorrhage, liver and renal failure, anemia and thrombocytopenia, infections or colonization with drug-resistant pathogens). Results: The analysis of the postoperative course showed that the patients with 5 AHASIT points or more had a more complicated postoperative course than the patients with 1 to 4 AHASIT points. Conclusions: The AHASIT of pediatric congenital heart defects with complex and non-cardiac problems appeared to be an attractive option for selected severely ill patients. The strategy was found to be effective in selected neonates suffering from complex and accompanying non-cardiac pathologies, with positive final results of both cardiological intervention and planned surgery.
2 citations
TL;DR: The case of a successful transatrial hybrid atrial septal defect (ASD II) closure in a borderline 9-month-old girl with multiple congenital defects is reported, with concomitant severe general comorbidities.
Abstract: We report the case of a successful transatrial hybrid atrial septal defect (ASD II) closure in a borderline 9-month-old girl with multiple congenital defects.
The patient, with hemodynamically significant ASD II, had scoliosis of the thoracic spine with multiple axial skeleton defects, including congenital defects of thoracic vertebrae, defects of the right ribs and agenesis of the sternum (Figure 1 A). Moreover, the patient suffered from overflow pulmonary hypertension, associated with hypoplasia of the right lung, hypotrophy with low body weight and height (< 3 percentile), and obstructive bronchitis (during pharmacological treatment and permanent nasal oxygen therapy). Intragastric tube feeding was carried out from birth. Despite intensive conventional treatment, the girl had permanent mixed inspiratory-expiratory dyspnea, with signs of central cyanosis, reduction of vesicular murmur on the right side, as well as rales and wheezing.
Figure 1
A – Preoperative X-ray: deformation of thorax with scoliosis, agenesis of ribs and sternum and displacement of diaphragm attachment upper to inferior thoracic aperture. B – Intraoperative epicardial echocardiography: provider coming to ...
The echocardiographic examination showed dilatation of the right ventricle (RV), right atrium (RA) and pulmonary artery (PA), paradoxical interventricular septal (IVS) motion, normal size and contractility of the left ventricle (LV), with ASD II (8–10 mm width) in the central area of the septum, with massive left-to-right shunt (Qp : Qs > 2.5 : 1), turbulent inflow from pulmonary veins to the left atrium, and elevated systolic pressure of the right ventricle (60–65 mm Hg).
After analysis of the heart defect and hemodynamic effects, with concomitant severe general comorbidities, in the face of clear contraindications to surgery (vascular positional anomalies) as well as to cardiac intervention from peripheral access (small venous diameter), the patient was electively qualified for hybrid transatrial ASD II closure.
The anterior minithoracotomy was made via the 4th intercostal space, where agenesis of the ribs was palpable. The upper lobe of the right lung was naturally expanded, the middle collapsed, and the lower in deep involution. The pericardial sac was opened above the RA in front of the right phrenic nerve. The heart was enlarged and rotated to the left, with enlargement of the RA. A purse string suture was made on the free wall of the RA and the arterial sheath was introduced. The size of the defect was measured in two dimensions using preoperatively transthoracic echocardiography (TTE) and intraoperatively epicardial echocardiography (Figure 1 B). Under guidance of transesophageal echocardiography (TEE) and epicardial echocardiography the Amplatzer Septal Occluder 9 mm (AGA, Med. Corp, Minneapolis, USA) was implanted in ASD II. Control epicardial echocardiography showed proper position of the occluder with complete closure of the defect. After removal of the provider and RA decannulation the thoracotomy was closed in layers. The girl was extubated 4 h postoperatively. Pharmacological treatment of sildenafil and aspirin (for 12 months, as scheduled) was started in the postoperative ward just after the first feeding [1]. In control TTE and chest X-ray the proper position of the implant with complete closure of the shunt was observed (Figures 1 C, ,D).D). The decrease of blood pressure in the PA was observed in control echocardiography and successful oral feeding was introduced on the second postoperative day.
The presented hybrid procedure allowed for successful closure of ASD II with reduction to a minimum of the risk of possible complications and adverse effects related to conventional cardiac surgery in the face of the critical comorbidities [2–4].
1 citations
01 Dec 2014
TL;DR: The authors report an interesting case of an adult patient with a coronary anomaly who underwent successful operative treatment and the presented morphology of coronary fistula with the effect of coronary ‘aneurysm’ was doubly unique because of its origin from the conal branch of the right coronary artery.
Abstract: The authors report an interesting case of an adult patient with a coronary anomaly who underwent successful operative treatment. The presented morphology of coronary fistula with the effect of coronary ‘aneurysm’ was doubly unique because of its origin from the conal branch of the right coronary artery. Congenital anomalies of coronary arteries are usually diagnosed early in childhood and can be an important, sometimes complicating factor in patients with various congenital heart defects. While asymptomatic the anomalies are diagnosed incidentally or during cardiac procedures for different indications in children [1]. It is natural that cardiac symptoms in adulthood are usually regarded as more typical for coronary artery disease or complex cardiovascular problems than as an effect of coronary anomalies. Nevertheless, following the report of Moodi F. with co-authors, it is worth keeping in mind that this rare pathology could also be a principal problem for patients at any age.
The authors report a patient who underwent diagnostics and surgical treatment after de novo 4-month long symptoms of progressive dypnea, probably as a clinical manifestation of heart insufficiency, although in the report it is not clearly explained if the patient had any prior cardiac symptoms or interventional history before admission. Currently the role of transthoracic two dimensional echocardiography with color Doppler in the diagnostics of an adult patient with pathological cardiac mass is essential. Nevertheless, I'll stress my cardiologist much more about the impact of the aneurysm on cardiac function, valvular flow patterns and the EF. There is some doubt whether the coronary angiogram could be completely normal in the presented individual. I would also be interested in the Qp/Qs ratio to assess the left-to-right shunt caused by the fistula. Modern computed tomography and cardiac magnetic resonance imaging could be useful methods to show more precisely the margins and the extent of the aneurysm before the operation.
The procedure of surgical excision of the aneurysm with cardiopulmonary bypass was reasonable, especially in the setting of unclear entry and the opening of the fistula [2]. I would definitely follow the decision and surgical strategy of the authors.
While the evaluation of the manuscript I made a brief analysis of patients with coronary anomalies in the experience of the Department of Pediatric Cardiac Surgery, Mikolaj Kopernik Hospital in Gdansk. In the total of more than 1600 pediatric cardiac procedures performed after the 1st of January 2008, anomalies of coronary arteries were diagnosed mostly in right heart lesions (ToF, PA), transpositions of the great arteries and an isolated anomalous left coronary artery from the pulmonary artery. Our goal is to diagnose precisely any coronary anomalies prior to the surgery to prevent any unexpected problems and improve the results, so angiography remains the gold standard in case of any doubts. In the outpatient group there are children with small isolated coronary fistulas who are regularly monitored because of murmurs. Our strategy is to postpone any interventional or surgical treatment unless their cardiac function remain in the normal range. In the pediatric group there is undoubtedly a great role for percutaneous transcatheter embolization techniques as first choice interventions [3], although the full spectrum of surgery and hybrid treatment is available in our heart team [4].
Finally, it is my great pleasure to recommend to Prof. Marian Zembala, Editor in Chief, and the Committee, the manuscript untitled “Coronary artery fistula: a huge conus branch aneurysm (case report)” for publication in the “Polish Journal of Cardiac and Thoracic Surgery”.
1 citations
Cites background from "Hybrid cardiovascular procedures in..."
...In the pediatric group there is undoubtedly a great role for percutaneous transcatheter embolization techniques as first choice interventions [3], although the full spectrum of surgery and hybrid treatment is available in our heart team [4]....
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References
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TL;DR: The hybrid approach can yield acceptable intermediate results that are comparable with a traditional Norwood strategy and provides the platform for a prospective trial comparing these two surgical options to assess whether there is less cumulative impact with the hybrid approach, thereby improving end organ function, quality, and quantity of life.
338 citations
TL;DR: Although the hybrid approach reduces the initial surgical insult, important interstage mortality and ongoing morbidity result in survival no different than with conventional surgical palliation.
Abstract: Objectives: Despite significant progress, surgical outcome for high-risk patients with hypoplastic left heart syndrome (HLHS) remain suboptimal. The hybrid palliation lessens the initial operative insult and is expected to improve overall survival; however the outcome of this management sequence is unknown. Methods: Retrospective review of all high-risk neonates (prematurity, low birth weight, associated genetic or co-morbid conditions) undergoing initial palliation for HLHS either by hybrid or Stage I Norwood procedure at a single institution between January 2001 and December 2006. The two strategies were compared using survival after stage II as the end-point for outcome.Results: The cohort included 33 patients (14 hybrid and 19 Norwood) with a mean age of 3.8 2.4 days, weight of 2.6 0.6 kg and Aristotle comprehensive score of 18.7 2.5. Aortic atresia was present in 5/14 hybrid and 12/19 Norwood patients. The mean gestational age was 36.8 2.2 weeks, six patients were under 36 weeks in each group. Patients undergoing hybrid palliation had a lower preoperative pH [7.14 0.2 vs 7.25 0.05, p = 0.04], higher incidence of organ dysfunction [9/14 (64%) vs 5/19 (26%), p = 0.03] and less associated cardiac anomalies [3/13 (21%) vs 13/19 (68%), p = 0.009]. Hospital mortality and interstage mortality was 7/33 (21%) and 6/26 (23%) for the entire cohort, without significant differences between the hybrid and the conventional Norwood strategies. Of the original 33 patients only 16 (48.5%) were alive following the second stage procedure (7/14 (50%) hybrid and 9/19 (47.4%) Norwood). Conclusions: Regardless of the type of initial palliation, high-risk neonates with HLHS continue to have decreased survival. Although the hybrid approach reduces the initial surgical insult, important interstage mortality and ongoing morbidity result in survival no different than with conventional surgical palliation. # 2008 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.
88 citations
TL;DR: A hybrid approach may be a valuable alternative to the management of high-risk neonates with hypoplastic left heart syndrome and its variants and is analyzed and report on the results with the hybrid approach.
75 citations
TL;DR: In this article, the authors evaluated 128 hybrid procedures and adverse events (AEs) of 128 procedures and found that 60% of interventional (vs. strictly diagnostic) hybrid procedures were performed by one center and the median weight was 3.7-86 kg.
Abstract: Introduction. Procedural cooperation between cardiac surgeon and interventional cardiologist to facilitate interventions such as device delivery or angioplasty (hybrid procedure) has become increasingly common in the management of patients with congenital heart disease.
Design. Data were prospectively collected using a multicenter registry (C3PO). Between February 2007 and December 2008, seven institutions submitted data regarding 7019 cardiac catheterization procedures. Procedural data and adverse events (AEs) of 128 hybrid procedures were evaluated.
Results. There was significant variability in the number of hybrid procedures per center, ranging from one to 89 with a median of eight. A total of 60% of interventional (vs. strictly diagnostic) hybrid procedures were performed by one center. The median weight was 3.7 kg (0.7–86 kg). Single-ventricle circulation was present in 60% of the procedures. Hybrid procedures included: patent ductus arteriosus (PDA) stent placement (n = 55), vascular rehabilitation (n = 25), ventricular septal defect (VSD) device closure (n = 7), valvotomy (n = 3), and diagnostic hybrid procedures (n = 38). Sixteen AEs occurred in 15/128 (12%) procedures. These included minor or trivial AEs (n = 9), moderate AEs (n = 5), major AEs (n = 1), and catastrophic AEs (n = 1). The type of AE documented included arrhythmias (n = 6), hypoxia or hypotension (n = 3), vessel or cardiac trauma (n = 2), and other events (n = 5). Of documented AEs, 9/16 (56%) were classified as not preventable, 6/16 (38%) as possibly preventable, and 1/16 (6%) as preventable. The incidence of AE related to PDA stent placement with surgical exposure (5/50, 10%) was significantly lower when compared with PDA stent placement performed percutaneously (4/5, 80%, P= .002).
Conclusion. Hybrid procedures appear to have a low incidence of associated major AEs. PDA stent placement performed as a palliation of hypoplastic left heart syndrome (HLHS) or complex single/two ventricle patients may have a lower incidence of AEs if performed using a direct approach with surgical exposure rather than a percutaneous approach. Accurate definitions of these innovative procedures are required to facilitate prospective data collection.
31 citations
"Hybrid cardiovascular procedures in..." refers methods in this paper
...These proce dures are used in the treatment of children with congenital heart disease (CHD) with atypical anatomy and associated additional limitations, or with borderline difficult anatomical variants of typical disease [1]....
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TL;DR: In this paper, a hybrid approach combining surgical and interventional catheterization procedures was introduced to minimize exposure to cardiopulmonary bypass, and improve outcomes for these high-risk infants.
Abstract: Purpose of review Despite progressive improvement in surgical results, hypoplastic left heart syndrome remains one of the congenital heart abnormalities with the greatest morbidity and mortality. Hybrid approaches to management, combining surgical and interventional catheterization procedures, have been introduced to minimize exposure to cardiopulmonary bypass, and improve outcomes for these high-risk infants. Recent findings First-stage palliation of hypoplastic left heart syndrome has been performed as a hybrid procedure combining surgical pulmonary artery banding with catheterization stenting of the ductus arteriosus and balloon atrial septostomy, especially in high-risk patients. Additionally, several centers have performed second-stage palliation – bidirectional Glenn or hemi-Fontan procedures – in a manner that allows the subsequent ‘Fontan’ procedure to be completed in the catheterization laboratory with a covered stent. Summary These innovative procedures offer the potential of an alternative management strategy for hypoplastic left heart syndrome. They have been applied to a very limited number of patients and long-term results are not available. Their role in management of hypoplastic left heart syndrome remains to be defined, especially as results of conventional surgical management continue to improve.
23 citations