Hybrid therapy for hypoplastic left heart syndrome: Myth, alternative, or standard—neither Minotaur nor Midas
2015; Elsevier BV; Volume: 151; Issue: 4 Linguagem: Inglês
10.1016/j.jtcvs.2015.10.099
ISSN1097-685X
Autores Tópico(s)Tracheal and airway disorders
ResumoCentral MessageThis large, single center study supports the hybrid technique for patients with hypoplastic left heart syndrome. Surgical versus hybrid palliation is in evolution.See Article page 1112.See Editorial page 909. This large, single center study supports the hybrid technique for patients with hypoplastic left heart syndrome. Surgical versus hybrid palliation is in evolution. See Article page 1112. See Editorial page 909. The development of a hybrid procedure for palliation of hypoplastic left heart syndrome (HLHS) was prompted by limited early success of the Norwood procedure.1Gibbs J.L. Wren C. Watterson K.G. Hunter S. Hamilton J.R. Stenting of the arterial duct combined with banding of the pulmonary arteries and atrial septectomy or septostomy: a new approach to palliation for the hypoplastic left heart syndrome.Br Heart J. 1993; 69: 551-555Crossref PubMed Scopus (191) Google Scholar, 2Pigott J.D. Murphy J.D. Barger G. Norwood W.I. Palliative reconstructive surgery for hypoplastic left heart syndrome.Ann Thorac Surg. 1988; 45: 122-128Abstract Full Text PDF PubMed Scopus (118) Google Scholar The hybrid procedure—stenting of the arterial duct combined with banding of the pulmonary arteries (PAs) and atrial septectomy—appeared to reawaken some of the presumed errors of early pediatric cardiac surgery; for example, bilateral PA banding, and seemed contrary to the trend toward earlier aggressive reparative neonatal cardiac surgery. Contemporaneously, results with stage I surgical palliation continued to improve, with experienced centers soon reporting in-hospital survival rates of 85% to 90% in standard-risk patients.3Iannettoni M.D. Bove E.L. Mosca R.S. Lupinetti F.M. Dorostkar P.C. Ludomirsky A. et al.Improving results with first stage palliation for hypoplastic left heart syndrome.J Thorac Cardiovasc Surg. 1994; 107: 934-940PubMed Google Scholar However, patients deemed to be at higher risk as a result of prematurity, very-low birth weight, chromosomal abnormalities, or pulmonary venous obstruction continued to experience mortality rates ranging from 25% to 40%. The hybrid procedure, by virtue of its avoidance of cardiopulmonary bypass and myocardial ischemia, was offered to these high-risk patients with surprisingly good results.4Bacha E.A. Daves S. Hardin J. Abdulla R.I. Anderson J. Kahana M. et al.Single-ventricle palliation for high risk neonates: the emergence of an alternative hybrid 1 strategy.J Thorac Cardiovasc Surg. 2006; 131: 163-171Abstract Full Text Full Text PDF PubMed Scopus (164) Google Scholar A few centers continued to refine the hybrid technique and offered it routinely to their patients with HLHS.5Galantowicz M. Cheatham J.P. Phillips A. Cua C.L. Hoffman T.M. Hill S.L. Rodeman R. Hybrid approach for hypoplastic left heart syndrome: intermediate results after the learning curve.Ann Thorac Surg. 2008; 85: 2063-2071Abstract Full Text Full Text PDF PubMed Scopus (331) Google Scholar The current study by Yerebakan and colleagues6Yerebakan C. Valeske K. Elmontaser H. Yörüker U. Mueller M. Thul J. et al.Hybrid therapy for hypoplastic left heart syndrome: Myth, alternative, or standard?.J Thorac Cardiovasc Surg. 2016; 151: 1112-1123.e5Abstract Full Text Full Text PDF PubMed Scopus (50) Google Scholar represents 1 of the largest single-center series of patients with HLHS routinely treated using a hybrid strategy. The Giessen Hybrid involves bilateral PA banding via sternotomy, followed 1 to 10 days later by ductal stenting and creation of a nonrestrictive atrial septal defect in the cardiac catheterization lab. Delaying the catheterization portion of the procedure, they believe, helps them to more accurately place the patent ductus arteriosus stent, assess the atrial defect, and allow for balloon enlargement of the previously placed PA bands if necessary. The current report is the latest update in their unselected patient population, with a median follow-up of more than 4.5 years. From a strictly survival standpoint (97.5% survival after stage I palliation and estimated 10-year survival of 79%), their results rival the best of centers performing the standard Norwood palliation.7Malik S. Bird T.M. Jaquiss R.D. Morrow W.R. Robbins J.M. Comparison of in-hospital and longer-term outcomes of hybrid and Norwood stage 1 palliation of hypoplastic left heart syndrome.J Thorac Cardiovasc Surg. 2015; 150: 474-480Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar Although the hybrid stage I palliation avoids significant reconstructive surgery during the neonatal period and likely leads to overall better early survival, this strategy despite its simplicity necessitates a more involved comprehensive stage II reconstruction often further complicated by the presence of significant branch PA stenosis and a difficult aortic arch reconstruction. This is evidenced by the greater than two-thirds of patients who required reinterventions on their branch PAs and 17% on the aortic arch. Furthermore, the interstage mortality remains appreciable at 12.2%. Although Yerebakan and colleagues6Yerebakan C. Valeske K. Elmontaser H. Yörüker U. Mueller M. Thul J. et al.Hybrid therapy for hypoplastic left heart syndrome: Myth, alternative, or standard?.J Thorac Cardiovasc Surg. 2016; 151: 1112-1123.e5Abstract Full Text Full Text PDF PubMed Scopus (50) Google Scholar purport to present “operative results, mortality, and morbidity” the only morbidities included relate to PA stenosis or recoarctation. Not included are the important parameters such as renal or respiratory insufficiency, rates of infection, and neurologic outcomes among others. Despite the above criticisms the authors should be applauded. Through their persistence and collective experience they have achieved commendable results in this difficult patient population. Proponents of the hybrid strategy have clearly outlined its potential benefits.8Galantowicz M. In favor of the hybrid stage I as the initial palliation for hypoplastic left heart syndrome.Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu. 2013; 16: 62-64Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar Yet a number of potential problems with this strategy persist:1.Bilateral PA banding, although often successful in limiting pulmonary blood flow, remains a crude procedure with little ability to adjust its effects. As borne out by the early history of congenital cardiac surgery, when left in situ for longer than a few weeks, it may have significant and long-lasting negative effects on the branch PAs.2.Stenting of the arterial duct, while avoiding an involved neonatal arch reconstruction, can in certain circumstances, lead to important retrograde aortic arch obstruction.9Calderone C.A. Benson L.N. Holtby H. Van Arsdell G.S. Main pulmonary artery to innominate artery shunt during hybrid palliation of hypoplastic left heart syndrome.J Thorac Cardiovasc Surg. 2005; 130: e1-e2Abstract Full Text Full Text PDF Scopus (59) Google Scholar This can, in concert with PA banding, lead to suboptimal cerebral and coronary blood flow.10Baker C.E. Corsini C. Consentino D. Dubini G. Pennati G. Migliavacca M. Effects of pulmonary artery banding and retrograde aortic arch obstruction on the hybrid palliation of hypoplastic left heart syndrome.J Thorac Cardiovasc Surg. 2013; 146: 1341-1348Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar The presence of the stent complicates the aortic arch reconstruction in comprehensive stage II palliation.3.Despite the potential benefits to neonates, interstage mortality remains significant. At this juncture although few centers favor the hybrid approach routinely,11Karamlou T. OVerman D. Hill K.D. Wallace A. Pasquali S.K. Jacobs J.P. et al.Stage 1 hybrid palliation for hypoplastic left heart syndrome-assessment of contemporary patterns of use: an analysis of the Society of Thoracic Surgeons Congenital Heart Surgery Database.J Thorac Cardiovasc Surg. 2015; 149: 195-202Abstract Full Text Full Text PDF PubMed Scopus (45) Google Scholar it appears that the concrete results of both the standard surgical Norwood palliation and hybrid approaches are strikingly similar. Both approaches can produce nearly equivalent early and intermediate-term survival rates.12Baba K. Kotani R. Chetan D. Chaturvedi R.R. Kyong-Jin L. Benson L.N. Hybrid versus Norwood strategies for single-ventricle palliation.Circulation. 2012; 126: S123-S131Crossref PubMed Scopus (82) Google Scholar, 13Brescia A.A. Jurdieini S. Danon S. Armbrecht E. Fiore A. Huddleston C. Hybrid versus Norwood procedure for hypoplastic left heart syndrome: Contemporary series from a single center.J Thorac Cardiovasc Surg. 2014; 147: 1777-1782Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar Much of the mortality and morbidity from the surgical Norwood palliation procedure is concentrated in the neonatal period. Survivors appear to have less likelihood of developing PA stenosis and critical aortic arch obstructions. The hybrid approach likely lowers neonatal mortality but may impose important intermediate- and long-term consequences predicated upon the need to closely observe and intervene, especially on the branch PAs.14Davies R.R. Radtke W.A. Klenk D. Pizzaro C. Bilateral pulmonary arterial banding results in an increased need for subsequent pulmonary artery interventions.J Thorac Cardiovasc Surg. 2014; 147: 706-712Abstract Full Text Full Text PDF PubMed Scopus (55) Google Scholar Mortality aside, a better characterization of the morbidity associated with the hybrid approaches is needed. Although not the standard, certainly the hybrid procedure is now a legitimate alternative to surgical Norwood palliation. With time it is likely that both the Norwood and hybrid approaches will be part of our armamentarium to deal with HLHS. A myth, no, but as is true with most innovations, at times it may be remembered as punitive or pure alchemy. Hybrid therapy for hypoplastic left heart syndrome: Myth, alternative, or standard?The Journal of Thoracic and Cardiovascular SurgeryVol. 151Issue 4PreviewThis retrospective study presents our operative results, mortality, and morbidity with regard to pulmonary artery growth and reinterventions on the pulmonary artery and aortic arch, including key features of our institutional standards for the 3-stage hybrid palliation of patients with hypoplastic left heart syndrome. Full-Text PDF Open Archive
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