| Historically, surgeons and interventionalists have had a somewhat competitive relationship, especially in adult cardiac disease, but can also be found in some congenital heart disease (CHD) centers. The management of complex CHD has improved due to advances in transcatheter therapies that coincide with surgical strategies. There still remain challenges for both disciplines that could be more easily overcome by a collaborative effort between surgeons, interventional cardiologists, as well as other Heart Center specialists. Webster's dictionary defines “hybrid” as a union or offspring of two distinct species, either animal or plant. Some may argue that surgeons and interventionalists are definitely two different species... however, we beg to differ. We will report our experiences in hybrid therapies for CHD, where all members of a Heart Center collaborate to achieve a common goal. There are certain prerequisites to implement a successful hybrid program. There can be no competition between the surgeon & interventionalist, economically or professionally, for new hybrid management strategies to evolve. There must be mutual respect for each other and the talents and limitations that each possess. No individual's opinion is weighted more than the other... it is a “partnership”. The goals of hybrid therapy are to: 1) reduce morbidity & mortality, 2) reduce the cumulative impact of interventions, 3) improve quality of life, and 4) deliver more efficient & cost effective care. As the level of collaboration between the surgeon and the interventionalist has increased, the need for a therapeutic suite that is compatible with both disciplines (hybrid) has become apparent. As such, we designed, built, and opened the world's first Hybrid Cardiac Catheterization Suites dedicated to CHD in June 2004, through the collaborative efforts of Toshiba Medical Systems Corporation, Stryker Communications, and the design & engineering teams from Columbus Children's Hospital. In addition, a new Hybrid Operative Suite will be opened in October of 2007. Since the initiation of our Heart Center, we performed 135 hybrid cardiac procedures in children and adults with complex CHD from July, 2002-May, 2007, with the following characteristics: age: 2 days-62 years (median 14 days), weight : 1.1-120 kg (median 3.5 kg) with 75% being≤2 years & 10 kg. We divided the procedures and patients into seven groups and are listed as follows: Group I: extreme premature neonates requiring interventions/vascular access (9); Group II: intraoperative stents (12); Group III: perventricular muscular VSD closure (6); Group IV: young adults requiring combined interventional therapy & EPS/pacemaker implant (33); Group V: unusual hybrid procedures (4); Group VI: intraoperative diagnostic angiography (12); and Group VII: PA bands & PDA stent for HLHS and other complex CHD (59). We performed the hybrid procedures in a traditional cath lab in 4 patients, in the cardiothoracic O.R. with mobile imaging equipment in 40, serially between the two locations in 16, and in our specially designed Hybrid Suites in 75. Since opening the Suites in mid 2004, we schedule all planned hybrid procedures in this venue as it offers the most versatility in achieving all of our goals. Successful implant of a perventricular RVOT stent in a 1.6 kg neonate of Jehovah Witness parents with pulmonary atresia & VSD avoiding the use of blood, transcarotid balloon aortic valvuloplasty in a 1.1 kg newborn, and placing a critically ill 2 kg patient with severe pulmonary hypertension secondary to bilateral pulmonary vein stenoses on ECMO in order to safely implant stents to await heart-lung transplant are some of the examples of the 9 successful hybrid interventional procedures performed in Group I patients. All 12 patients undergoing intraoperative stent implantation in Group II were successful, both on and off cardiopulmonary bypass. This included both bare and covered stent implants to reconnect isolated pulmonary arteries that would not have been possible with traditional surgical or transcatheter approach. We use endoscopically-assisted placement of the stent if the patient is on CPB(Fig. 1a-d). Four of the six patients, ranging from 2 weeks to 5 years, undergoing perventricular muscular VSD closure off CPB using the AMPLATZER m-VSD occluder were successful in Group III. Failures included a small infant with a high m-VSD where the septum was too thin for the 7 mm length of the device waist and another patient where the largest 18 mm device was not large enough to close the defect. These two patients had successful surgical closure, while the other four had complete closure using one or multiple devices. All 33 young adults who were post-op Mustard's repair for TGA in Group IV had successful implant of bare and/or covered stents for SVC baffle obstruction and/or leaks along with occlusion devices as needed. Immediate implant of a transvenous pacemaker or implantable cardiovertor defibrillator (ICD) was performed in 23 patients. This requires a collaborative hybrid approach by the interventional, electrophysiology, and adult congenital heart services to accomplish this result in a single, long catheterization procedure. We performed 4 very unusual hybrid cardiac procedures in Group V, highlighted by a 34-year-old woman who presented to our adult institution in severe LV failure, systemic hypertension, and 24 weeks pregnant. She was ultimately diagnosed with near complete interruption of the aorta (CoA) and treated with anti-congestive and anti-hypertensive medications for 1 month. However, the risk for demise of the fetus and the mother was felt to be high and she was referred to our Heart Center for treatment... even though we had no obstetrics or delivery service. After coordinating the procedure with CT surgical back-up, neonatal ICU presence, adult CHD service input, and the high-risk obstetrical service team that was granted privileges at CCH, we performed the hybrid procedure. A covered stent was implanted with complete relief of the gradient and the fetal heart rate remained stable for 1 hour, but then plummeted to 60 beats/min and an emergency C-section was performed in Suite 1 secondary to presumed “abruptio placenta” from the pulsatile blood flow to the placenta. A 1 kg baby boy was delivered, transferred, and resuscitated in Suite 2. Both mother and baby were later discharged in excellent condition because of careful planning and collaboration of multiple services. In the 12 patients in Group VI, an intraoperative angiogram was performed to confirm or rule out possible anatomic abnormalities after intracardiac repair of complex CHD. We believe the ability to perform angiograms easily and quickly in the operative suite will provide a new venue to immediately treat less than desirable anatomical results using hybrid technology in the future. This will be tested in our soon to open Hybrid Operative Suite with a single plane Toshiba FPD mounted strategically in the Suite. The largest group of patients were in Group VII (59), where we placed LPA & RPA surgical bands using either 3.0 or 3.5 mm Gore-Tex strips and a PDA stent, either self or balloon expandable, through a small median sternotomy incision and purse string into the MPA above the pulmonary valve without the use of CPB(Fig. 2a, b).The most common indication was HLHS or other complex single ventricular anatomy in 55 of the 59 newborns, weighing from 1.1 to 4.0 kg, or for palliation in 4 babies with possible 2 ventricular repair in three JHW families and a newborn weighing 1.1 kg. There was only 1 procedural death in a newborn with unrecognized obstruction to retrograde aortic arch flow where the PDA stent completely blocked flow to the arch vessels and coronary arteries and 3 hospital deaths... which was amazing considering at least 6 of these patients were from 1.1 to 1.8 kg, and 10 others < 2.5 kg... all extremely high risk for traditional Norwood procedure. In summary, hybrid cardiac procedures: 1) lessen morbidity, mortality, & encourage innovative management strategies with a mortality of 1 procedural death ( < 1%) & 3 in-house fatalities ( < 3%)... which is remarkable considering the complexity of CHD and size of these patients; 2) requires a collaborative, non-competitive relationship between the interventionalist & CT surgeon... as well as support by all Heart Center staff; 3) a new venue, the Hybrid Cardiac Catheterization or Operative Suite, can now be designed to accommodate all of the specialists in a Heart Center dedicated to this novel treatment of CHD; and 4) strong hospital administrative support is imperative because of the initial cost of establishing such program... which is the future that will open everyone's minds to endless possibilities! |
