title: Single-ventricle palliation for high-risk neonates: the emergence of an alternative hybrid stage I strategy.
abstract: BACKGROUND
  Survival after stage I palliation for hypoplastic left heart syndrome or related anomalies remains poor in high-risk neonates. We hypothesized that a less invasive hybrid approach would be beneficial in this patient population.
  
  
  METHODS
  The hybrid stage I procedure was performed in the catheterization laboratory. Via a median sternotomy, both branch pulmonary arteries were banded, and a ductal stent was delivered via a main pulmonary artery puncture and positioned under fluoroscopic guidance.
  
  
  RESULTS
  Between October 2003 and June 2005, 14 high-risk neonates underwent a hybrid stage I procedure. Eleven of 14 had hypoplastic left heart syndrome. Two also underwent peratrial atrial septal stenting, and 5 required percutaneous atrial stenting later. Two neonates with an intact or highly restrictive atrial septum had emergency percutaneous atrial stent placement. Hospital survival was 11 (78.5%) of 14. One patient required extracorporeal membrane oxygenation support for intraoperative cardiac arrest. He underwent cardiac transplantation but died later of sepsis. One patient died of ductal stent embolization, and a third died of progressive cardiac dysfunction. The first 4 patients required pulmonary artery band revisions. There were none after we modified our technique and added branch pulmonary artery angiograms. There were 2 interstage deaths from atrial stent occlusion and from preductal retrograde coarctation. Eight patients underwent stage II procedures, consisting of aortic arch reconstruction, atrial septectomy, and cavopulmonary shunt. Two patients died after stage II. One patient is awaiting stage II.
  
  
  CONCLUSIONS
  The hybrid stage I palliation is a valid option in high-risk neonates. As experience is accrued, it may become the preferred alternative. However, in aortic atresia, the development of preductal retrograde coarctation is a significant problem.
authors.affiliation: Department of Congenital and Pediatric Cardiac Surgery, The University of Chicago Children's Hospital, Chicago, Ill, USA. emile.bacha@cardio.chboston.org
authors.forename: Emile A
authors.initials: EA
authors.lastname: Bacha
authors.forename: Suanne
authors.initials: S
authors.lastname: Daves
authors.forename: Joel
authors.initials: J
authors.lastname: Hardin
authors.forename: Ra-id
authors.initials: RI
authors.lastname: Abdulla
authors.forename: Jennifer
authors.initials: J
authors.lastname: Anderson
authors.forename: Madelyn
authors.initials: M
authors.lastname: Kahana
authors.forename: Peter
authors.initials: P
authors.lastname: Koenig
authors.forename: Bassem N
authors.initials: BN
authors.lastname: Mora
authors.forename: Mehmet
authors.initials: M
authors.lastname: Gulecyuz
authors.forename: Joanne P
authors.initials: JP
authors.lastname: Starr
authors.forename: Ernerio
authors.initials: E
authors.lastname: Alboliras
authors.forename: Satinder
authors.initials: S
authors.lastname: Sandhu
authors.forename: Ziyad M
authors.initials: ZM
authors.lastname: Hijazi
mesh_terms: D006348:Cardiac Surgical Procedures / Q000009:adverse effects / Q000379:methods; D006801:Humans; D018636:Hypoplastic Left Heart Syndrome / Q000150:complications / Q000601:surgery*; D007231:Infant, Newborn; D011183:Postoperative Complications / Q000453:epidemiology; D012307:Risk Factors