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J Thorac Cardiovasc Surg 2006;131:163-171
© 2006 The American Association for Thoracic Surgery

Surgery for Congenital Heart Disease

Single-ventricle palliation for high-risk neonates: The emergence of an alternative hybrid stage I strategy

Emile A. Bacha, MD a , * , Suanne Daves, MD b , Joel Hardin, MD c , Ra-id Abdulla, MD c , Jennifer Anderson, MD c , Madelyn Kahana, MD b , Peter Koenig, MD c , Bassem N. Mora, MD a , Mehmet Gulecyuz, MD c , Joanne P. Starr, MD a , Ernerio Alboliras, MD c , Satinder Sandhu, MD c , Ziyad M. Hijazi, MD c

a Department of Congenital and Pediatric Cardiac Surgery, The University of Chicago Children's Hospital, Chicago, Ill.
b Department of Anesthesia and Critical Care, The University of Chicago Children's Hospital, Chicago, Ill.
c Department of Pediatric Cardiology, The University of Chicago Children's Hospital, Chicago, Ill.

Read at the Eighty-fifth Annual Meeting of The American Association for Thoracic Surgery, San Francisco, Calif, April 10-13, 2005.

Received for publication April 8, 2005; revisions received July 14, 2005; accepted for publication July 19, 2005.

* Address for reprints: Emile A. Bacha, MD, Cardiac Surgery, Children's Hospital Boston, 300 Longwood Ave, Bader 273, Boston, MA 02115. (Email: emile.bacha{at}cardio.chboston.org).

BACKGROUND: Survival after stage I palliation for hypoplastic left heart syndrome or related anomalies remains poor in high-risk neonates. We hypothesized that a less invasive hybrid approach would be beneficial in this patient population.

METHODS: The hybrid stage I procedure was performed in the catheterization laboratory. Via a median sternotomy, both branch pulmonary arteries were banded, and a ductal stent was delivered via a main pulmonary artery puncture and positioned under fluoroscopic guidance.

RESULTS: Between October 2003 and June 2005, 14 high-risk neonates underwent a hybrid stage I procedure. Eleven of 14 had hypoplastic left heart syndrome. Two also underwent peratrial atrial septal stenting, and 5 required percutaneous atrial stenting later. Two neonates with an intact or highly restrictive atrial septum had emergency percutaneous atrial stent placement. Hospital survival was 11 (78.5%) of 14. One patient required extracorporeal membrane oxygenation support for intraoperative cardiac arrest. He underwent cardiac transplantation but died later of sepsis. One patient died of ductal stent embolization, and a third died of progressive cardiac dysfunction. The first 4 patients required pulmonary artery band revisions. There were none after we modified our technique and added branch pulmonary artery angiograms. There were 2 interstage deaths from atrial stent occlusion and from preductal retrograde coarctation. Eight patients underwent stage II procedures, consisting of aortic arch reconstruction, atrial septectomy, and cavopulmonary shunt. Two patients died after stage II. One patient is awaiting stage II.

CONCLUSIONS: The hybrid stage I palliation is a valid option in high-risk neonates. As experience is accrued, it may become the preferred alternative. However, in aortic atresia, the development of preductal retrograde coarctation is a significant problem.

Abbreviations and Acronyms CPB = cardiopulmonary bypass; HLHS = hypoplastic left heart syndrome; PA = pulmonary artery; PTFE = polytetrafluoroethylene




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