Stage II reconstruction after hybrid palliation for high-risk patients with a single ventricle

Background. The hybrid approach to palliate high-risk neonates with a single ventricle and systemic outflow obstruction continues to gain interest. Despite early success, few data exist regarding the physiologic adequacy of this palliation and the outcome of the stage II reconstruction. Methods. We reviewed our experience with stage II reconstruction after hybrid palliation in high-risk newborns with hypoplastic left heart syndrome and variants, focusing on the hemodynamic, reintervention, and operative data. Results. Among 14 patients undergoing hybrid palliation, interstage reinterventions targeted the ductal stent in 2, the atrial septal communication in 3, and the pulmonary artery bands in 1 patient. The median ratio of pulmonary blood flow to systemic blood flow (Qp/Qs) was 0.76, and pulmonary artery pressure was 14 mm Hg. Stage II reconstruction was performed in 8 patients with a median age of 4 months (range, 3.2 to 5.8 months) and a median weight of 4.9 kg (range, 3.7 to 6.0 kg). Median cardiopulmonary bypass time was 124 minutes (range, 95 to 188 minutes). Median time to extubation was 20 hours (range, 9 to 120 hours). Median oxygen saturation at hospital discharge was 79% (range, 78% to 82%). Two perioperative deaths occurred. To date, all hospital survivors are well. Four patients have completed a Fontan. Conclusions. Stage II reconstruction after hybrid palliation for high-risk neonates carries important morbidity and mortality. A considerable number of reinterventions to optimize the palliated physiology are necessary. This approach can provide appropriate preparation for single-ventricle management while avoiding cardiopulmonary bypass in the neonate. Additional experience and critical risk assessment of the entire strategy are necessary to define its advantages.