title: Hybrid therapy for hypoplastic left heart syndrome: Myth, alternative, or standard?
abstract: OBJECTIVE
  This retrospective study presents our operative results, mortality, and morbidity with regard to pulmonary artery growth and reinterventions on the pulmonary artery and aortic arch, including key features of our institutional standards for the 3-stage hybrid palliation of patients with hypoplastic left heart syndrome.
  
  
  METHODS
  Between June 1998 and February 2015, 182 patients with hypoplastic left heart structures underwent the Giessen hybrid stage I procedure. Among these, 126 patients with hypoplastic left heart syndrome who received a univentricular palliation or heart transplantation were included in the main analysis. Median age and body weight of patients at hybrid stage I were 6 days (0-237) and 3.2 kg (1.2-7), respectively. Comprehensive stage II operation was performed at 4.5 months (2.9-39.5), and Fontan completion was established at 33.7 months (21.1-108.2). Operative and interstage mortality, morbidity, growth and reinterventions on the pulmonary arteries, and long-term operative results of the aortic arch reconstruction were assessed.
  
  
  RESULTS
  Median follow-up time after Giessen hybrid stage I palliation was 4.6 years (0-16.8). Operative mortality at hybrid stage I, comprehensive stage II, and Fontan completion was 2.5%, 4.9%, and 0%, respectively. Cumulative interstage mortality was 14.2%. At 10 years, the probability of survival is 77.8%. Body weight (<2.5 kg) and aortic atresia had no significant impact on survival. McGoon ratio did not differ at comprehensive stage II and Fontan completion (P = .991). Freedom from pulmonary artery intervention was estimated to be 32.2% at 10 years. Aortic arch reinterventions were needed in 16.7% of patients; 2 reoperations on the aortic arch were necessary.
  
  
  CONCLUSIONS
  In view of the early results and long-term outcome, the hybrid approach has become an alternative to the conventional strategy to treat neonates with hypoplastic left heart syndrome and variants. Further refinements are warranted to decrease patient morbidity.
authors.affiliation: Pediatric Heart Center Giessen, Justus-Liebig-University, Giessen, Germany. Electronic address: can.yerebakan@med.uni-rostock.de.
authors.forename: Can
authors.initials: C
authors.lastname: Yerebakan
authors.affiliation: Pediatric Heart Center Giessen, Justus-Liebig-University, Giessen, Germany.
authors.forename: Klaus
authors.initials: K
authors.lastname: Valeske
authors.affiliation: Pediatric Heart Center Giessen, Justus-Liebig-University, Giessen, Germany.
authors.forename: Hatem
authors.initials: H
authors.lastname: Elmontaser
authors.affiliation: Pediatric Heart Center Giessen, Justus-Liebig-University, Giessen, Germany.
authors.forename: Uygar
authors.initials: U
authors.lastname: Yörüker
authors.affiliation: Pediatric Heart Center Giessen, Justus-Liebig-University, Giessen, Germany.
authors.forename: Matthias
authors.initials: M
authors.lastname: Mueller
authors.affiliation: Pediatric Heart Center Giessen, Justus-Liebig-University, Giessen, Germany.
authors.forename: Josef
authors.initials: J
authors.lastname: Thul
authors.affiliation: Pediatric Heart Center Giessen, Justus-Liebig-University, Giessen, Germany.
authors.forename: Valesco
authors.initials: V
authors.lastname: Mann
authors.affiliation: Pediatric Heart Center Giessen, Justus-Liebig-University, Giessen, Germany.
authors.forename: Heiner
authors.initials: H
authors.lastname: Latus
authors.affiliation: Pediatric Heart Center Giessen, Justus-Liebig-University, Giessen, Germany.
authors.forename: Anika
authors.initials: A
authors.lastname: Villanueva
authors.affiliation: Pediatric Heart Center Giessen, Justus-Liebig-University, Giessen, Germany.
authors.forename: Karoline
authors.initials: K
authors.lastname: Hofmann
authors.affiliation: Pediatric Heart Center Giessen, Justus-Liebig-University, Giessen, Germany.
authors.forename: Dietmar
authors.initials: D
authors.lastname: Schranz
authors.affiliation: Pediatric Heart Center Giessen, Justus-Liebig-University, Giessen, Germany.
authors.forename: Hakan
authors.initials: H
authors.lastname: Akintuerk
mesh_terms: D000293:Adolescent; D001013:Aorta, Thoracic / Q000503:physiopathology / Q000601:surgery; D019917:Blood Vessel Prosthesis Implantation; D002648:Child; D002675:Child, Preschool; D018729:Fontan Procedure / Q000009:adverse effects / Q000401:mortality; D005858:Germany; D006801:Humans; D018636:Hypoplastic Left Heart Syndrome / Q000175:diagnosis / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D007223:Infant; D053208:Kaplan-Meier Estimate; D058327:Norwood Procedures / Q000009:adverse effects / Q000401:mortality; D010166:Palliative Care; D011651:Pulmonary Artery / Q000254:growth & development / Q000601:surgery; D011652:Pulmonary Circulation; D012086:Reoperation; D012189:Retrospective Studies; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome
keywords: hybrid treatment; hypoplastic left heart syndrome; outcome; pulmonary arteries; reinterventions; survival