OUR TECHNIQUE FOR THE HYBRID PROCEDURE IN HYPOPLASTIC LEFT HEART SYNDROME

1. OUR TECHNIQUE FOR THE HYBRID PROCEDURE IN HYPOPLASTIC LEFT HEART SYNDROME Drs. Luis León, Stephan Haecker, Daniel Pérez, Luis Cárdenas, Miguel A. Santis. Centro Cardiovascular Pediátrico, Clínica Santa María, Santiago,Chile.

2. *The Norwood procedure is our first choice in the surgical treatment of Hypoplastic Left Heart Syndrome. *We have adopted the HYBRID PROCEDURE as an emergency treatment whenever the Norwood operation carries a higher risk due either to poor preoperative hemodynamic conditions, or to severe pediatric problems. *The Hybrid Procedure may offer inmediate hemodynamic gain and an improved outcome in these patiens.

3. HYBRID PROCEDURE TECHNIQUE STAGE 1 IN THE PEDIATRIC CARDIAC OPERATING ROOM BANDING RIGHT AND LEFT PULMONARY ARTERY

4. STAGE 1 1. STERNOTOMY 2. PREPARING GORETEX BANDS 3. RPA AND LPA DISSECTION 4. RPA BANDING 5. LPA BANDING AORTA ductus RPA LPA PA LV RV

5. *STERNOTOMY *FINDINGS: dilated PA at systemic presure, minute aorta(2,5-3,5 mm), very large patent ductus obscuring the LPA Ductus aorta Pulmonary artery Right Ventricle

6. *Limited dissection between PA and aorta reduces the chance of inadvertent occlusion Ductus aorta Pulmonary artery Right Ventricle

7. *Two Goretex rings 2 to 3 mm wide are produced from a 3.5 mm tube Goretex 3.5 mm 3.5 GORETEX TUBE

8. *A 5/0 Prolene mattress stitch is sutured on the upper end keeping near the free edge *After surrounding the PA branch the suture is passed through the lower end and tied

9. *RPA & LPA banding does not require pump support

10. *The assistant surgeon carefully displaces the pulmonary artery and aorta towards the left, avoiding both aortic occlusion (myocardial ischemia) and ductal occlusion (sistemic hypotension), as well as pulmonary valve distortion (sistemic valve incompetence) *a traction suture is placed on the right atrial appendage if necessary RPA SVC RA

11. *a minimum of dissection around the RPA is necessary *the Goretex ring is passed behind it, and the artery is subsequently banded

12. *the Goretex ring is passed behind it, and the artery is subsequently banded

13. *the right pulmonary artery is now banded.

14. The assistant surgeon will now displace both arteries to the right, revealing the LPA. Again, kinking the aorta, occluding the PDA and producing pulmonary valve incompetence are carefully avoided. LPA

15. Limited dissection around the LPA origin Is necessary.

16. The second Goretex ring is passed behind the LPA and sutured The external diameter of the banded LPA is approximately 3 mm

17. The second Goretex ring is passed behind the LPA and sutured The external diameter is approximately 3 mm

18. The external diameter is approximately 3 mm. It can be further reduced with an additional stitch • HEMODYNAMIC CHANGES: • Systolic and diastolic pressure increase, and so does systemic flow. • Pulmonary flow is moderately reduced, expected PO2 is 40 to 50 mm Hg • with O2 sat ranging from 80 to 90%

19. HYBRID PROCEDURE TECHNIQUE STAGE 2 IN THE PEDIATRIC CATH LAB PATENT DUCTUS STENTING

20. STAGE 2 Sternotomy A pursestring suture is placed in the sinotubular junction of the pulmonary artery. 2. A catheter intoducer is advanced 3. PA angiogram 6. Ductus measurements and STENT CHOICE 7. DUCTAL STENT DELIVERY

21. a Prolene pursestring • is placed at the sinotubular junction of the pulmonary artery

22. *A Nº7 intoducer is advanced into the PA *it is positioned 5 mm inside the PA *a test injection is performed

23. * ANGIO INFORMATION: * Ductus shape *Aortic arch shape (it may superimpose on the PDA) *Degree of branch PA banding

24. DUCTUS MEASUREMENT ductus width is measured at the pulmonary end

25. DUCTUS MEASUREMENT *Duct length is now measured along its center

26. STENT CHOICE *THE DUCT STENT MUST BE 1 OR 2 MILIMETERS LARGER THAN THE DUCT WIDTH (Eg: 8 mm stent for a 7 mm Duct ) *SELF EXPANDING DUCT STENTS ARE USUALLY 20 MM LONG *Baloon dilatation of a normal stent will stop systemic flow during the procedure 8 mm 20 mm

27. COLOCACIÓN DEL STENT *Stent Delivery: *The guide wire is advanced across the duct far into the descending aorta

28. COLOCACIÓN DEL STENT *The stent device is now in place: *The sheath has two radioopaque marks indicating de stent’s position

29. COLOCACIÓN DEL STENT *Stent delivery has begun as the cardiologist removes the sheath and a second cardiologist ,or surgeon holds the introducer during radioscopy *The stent tips are radioopaque. They show the actual position of the stent. Minor changes in position can still be achieved. If the stent has moved inwards, gently pull the introducer back.

30. COLOCACIÓN DEL STENT *The stent is 50% delivered. The position looks right

31. COLOCACIÓN DEL STENT *The stent is fully expanded *It is important that the proximal end be stented

32. COLOCACIÓN DEL STENT *We perform a final injection to check on flow through the ductus and retrograde flow in the aortic arch.

33. ç CASE 2 *Chest X-ray: The stent is shown in the anteroposterior view

34. CASE 2 *stent in lateral view

35. CASE 1 Angiogram for ductus measurement and stent choice

36. CASE 1 Ductal stent being delivered

37. CASE 1 Angiogram showing ductal and aortic patency after stent delivery

38. CASE 2 Angiogram for ductus measurement and stent choice

39. CASE 2 Angiogram evaluation of branch PA banding

40. CASE 2 Angiogram for ductus measurement and stent choice Inyección para medición del ductus y elección del stent

41. CASE 2 Ductal stent being delivered, initial phase Colocación del stent ductal

42. CASE 2 Ductal stent delivery completed Colocación del stent ductal

43. CASE 2 Angiogram showing ductal and aortic patency after stent delivery

44. CASE 3 Angiogram for ductus measurement and stent choice

45. CASE 3 Ductal stent being delivered

46. CASE 3 Angiogram shows that the proximal end of the duct is not covered by the stent

47. CASE 3 Second ductal stent being delivered

48. CASE 3 Angiogram showing ductal and aortic patency after second stent