Hybrid Procedure

Procedure. The hybrid procedure (so-called because it typically includes both surgical and catheter-based interventions) is an approach to single ventricle palliation in situations in which it is desirable to avoid CPB. It includes three main components, which may be performed in any combination.

  1. Pulmonary blood flow is limited using branch PA bands. These are typically made of suture, which is non-distensible, but at times elastic material (e.g. VessiLoop) can be used, in which case the diameter of the band varies with blood pressure. This is often a vital step to balancing the circulation as the PVR decreases, increasing systemic blood flow by increasing resistance to PBF. Monitor for distal migration of the PAB, which can occlude flow to one of the PA branches.
  2. By definition, the PDA must be kept patent in the single ventricle circulation, and this may be performed either via PDA stenting or by continuing PGE infusion. In the case of aortic atresia, PDA stenting must be performed with caution, as coronary and cerebral blood flow takes place exclusively retrograde, and patients with a microaorta (e.g. 2-3 mm) are at risk for coronary insufficiency, aortic root thrombus, or retrograde coarctation. In some cases in which the hybrid is being used as a bridge to a more definitive procedure (e.g S1P or transplant), PGE infusion may be continued.
  3. In cases in which the atrial septum is restrictive, it is important to evaluate for signs of LA HTN. An LAP >10-15 mmHg indicates that the LV is unable to efficiently receivepulmonary venous return (because of poor ventricular compliance and/or elevated Qp). In these settings, decompressing the atrium by BD and stenting may decrease LAP and improve lung health.
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