招請講演IV 
Hybrid approach to the patient with hypoplastic left heart syndrome: Evolution of staged palliation
Chief of Cardiology, The Heart Center at Columbus Children's Hospital, Ohio State University, Columbus, Ohio, USA
Timothy F. Feltes
While in the past two decades advances in the surgical, interventional and intensive care management have improved the outcome for patients with hypoplastic left heart syndrome, the results remain suboptimal for the traditional staged repair of these patients. The greatest risk centers around the initial palliation (Stage I Norwood procedure). Utilizing innovative surgical and transcatheter techniques, Dr. Mark Galantowicz and Dr. John Cheatham of The Heart Center at Columbus Children's Hospital along with others have developed a hybrid strategy for the management of these patients that involves a single comprehensive open heart procedure (combining components of traditional stage 1, 2 and 3 operations) flanked by two less invasive procedures to achieve the Fontan circulation.
In the initial palliation of these patients, the goals include: 1) creation of unobstructed systemic blood flow via the patent ductus arteriosus (PDA), 2) balancing of the pulmonary and systemic blood flow, and 3) relief of any obstruction at the atrial septum. To achieve these goals, patients are taken to the operative suite where bilateral pulmonary artery banding is performed without the use of cardiopulmonary bypass along with insertion of a short sheath in the main pulmonary artery. From this sheath a self-expanding PDA stent is positioned (portable, digital angiographic system) and released. Placement of an atrial septal stent is performed during a separate catheterization procedure.
Patients are closely monitored for evidence of ventricular dysfunction, development of prograde (traditional site) or retrograde (transverse arch) coarctation and degree of cyanosis during the interstage monitoring. A surveillance cardiac catheterization is typically performed at six weeks post-hybrid stage I.
Stage II of the hybrid approach is a comprehensive surgical procedure with the goals of: 1) to achieve surgical relief of the anatomical aortic arch obstruction and 2) to relieve the volume load from the right ventricle by creating a partial cavopulmonary anastomosis. Therefore, Stage II includes removal of the PDA and atrial septal stents and pulmonary artery bands, Norwood stage I aortic arch repair, and a modified cavopulmonary anastomosis that is designed to facilitate the transcatheter Fontan completion.
Finally, stage III of the hybrid approach is a transcatheter completion of the Fontan circulation. It is performed at approximately two years of age. The inferior vena caval blood flow is diverted to the pulmonary circulation by inserting a covered stent(s) between the inferior vena cava and the proximal superior vena caval-pulmonary artery anastomosis. These stents are expanded to a size determined by the size of the inferior venal cava but capable of future dilation.
The evolution of this strategy will be presented.


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