Some children with heart disease are best treated with a hybrid approach, one that combines both surgery and catheterization, or a catheter-based procedure. In a catheter-based procedure, a thin, flexible tube, or catheter, is inserted into the arteries and guided to the heart to deliver treatment. For example, a hole in the heart may be closed by guiding a small closure device through the catheter to the opening and using it to plug the hole.
Hybrid procedures are performed in a hospital suite equipped for both open heart surgery and catheterization. The medical team includes both a pediatric heart surgeon and an interventional cardiologist, a heart specialist trained in performing catheterization procedures. Also in attendance are other pediatric care specialists and technologists.
A child who undergoes a hybrid procedure is given an anesthetic and put to “sleep.” The chest is opened through a surgical wound. In many cases, the opening may be small – just large enough to allow access to the heart. Smaller surgical wounds allow faster recovery and reduced scarring.
In a hybrid procedure, the pediatric heart surgeon repairs the heart’s structures. Then, an interventional cardiologist guides a catheter through the arteries to the area(s) in the heart in need of repairs that are best made using a catheter-based procedure.
The risks and possible complications associated with hybrid procedures are the same as those indicated for catheterization procedures and surgical procedures.
Heart Defects That May Be Treated With a Hybrid Procedure
The physician will tailor the best treatment plan for your child’s heart condition. The following conditions are among those that may be treated with a hybrid procedure:
A hybrid approach may be taken to close a hole (atrial septum defect) in the wall between the heart’s two upper chambers. A surgeon makes an incision to expose the heart and create an opening in the exterior heart wall to provide easier access to the ASD. Then, to close the ASD, an interventional cardiologist inserts a catheter into an artery in the heart and guides it to the ASD where it delivers a small closure device to plug the opening. This procedure is performed with the heart beating normally.
When a heart valve fails to open normally and restricts blood flow through or out of the heart, a hybrid procedure may be used to widen the valve opening. First, a surgical procedure exposes the heart and opens its outside wall to allow easier access to the valve. Then, a catheter with an uninflated balloon on its tip is guided through the heart and positioned inside the valve. There, the balloon is inflated to push the valve opening wider. This procedure is performed with the heart beating normally.
In a VSD, one or more small holes are present in the wall between the heart’s two lower chambers (ventricles). Smaller holes may close on their own; others may be repaired with a closure device delivered via a catheter that is inserted into an artery in the groin or neck and guided through the vessels to the heart. However, some VSDs are difficult to reach when the catheter is inserted in the groin or neck. In these cases, a hybrid approach may be employed: An opening in the heart wall is created surgically to provide easier access for delivering the catheter and closure device to the VSD.
In HLHS, one of the most serious heart defects in children, the small size of the left ventricle and aorta render them useless. Thus, repairing the heart’s lower chamber, which pumps blood to the body, and the main vessel, which carries blood from the heart to the body, is critical. In the past, repair has required reconstructive open heart surgery performed over three to four stages, the first of which occurred when the baby was just 1-2 weeks old.
Now, because studies have found that surgery during the newborn period and the number of open heart surgeries required can have a negative impact on the child, a hybrid procedure has been devised. It reduces the number of open heart surgical procedures needed from three or four to one – and enables doctors to delay the child’s open heart surgery to age 4-to-6 months, when the risks are lower and the results are likely to be better.
The hybrid procedure for HLHS is performed as follows:
First Stage: The first stage in the hybrid procedure, performed in the first two weeks of the baby’s life, does not require open heart surgery, but it does require an open chest procedure. An assessment prior to this stage is made to determine if the hole between the upper chambers of the heart is large enough to allow sufficient blood to pass through. If the hole is big enough, then the first stage is performed in the hybrid suite. If the hole is not big enough, prior to the first stage, the baby will be taken to the cath lab where the hole will be opened or widened with a balloon or stent.
During the first stage procedure, the surgeon opens the chest to expose the heart. He or she then places bands around the branch pulmonary arteries to restrict blood flow to the lungs. This helps send most of the blood ejected from the right ventricle through the patent ductus arteriosus to the body, rather than allowing it to flow to the lungs.
Then, the interventional cardiologist introduces a catheter directly through the pulmonary artery and deploys a stent in the patent ductus arteriosus, a vessel essential to fetal circulation that normally closes soon after birth. Inserting the stent to keep the vessel open keeps oxygen-rich blood moving into the aorta and out to the body. At the end of this procedure, prostaglandin (the medication the baby receives at birth to keep the ductus open) can be discontinued. The chest is closed and the baby is moved into the intensive care unit.
Second Stage: At 4–8 months of age, the child undergoes open heart surgery to repair the small aorta and to place a Glenn shunt, a passageway which provides the lungs with a stable source of blood flow. Prior to the operation, a cardiac catheterization may be needed to check the pressure in the lungs and assess the pulmonary arteries and the aorta.
Third Stage: At 1–2 years of age, the child returns for an interventional procedure (a surgical procedure at some hospitals) to divert all blood coming back to the heart into the lung circulation. This is referred to as the Fontan procedure. Again, prior to the operation, a comprehensive cardiac catheterization is performed to assess the pressure in the lungs and to examine the aortic arch.