Hybrid Procedures for Congenital Heart Repair:

Aortic Arch Stenting

Redmond P. Burke MD, FACS

Chief, Division of Cardiovascular Surgery
The Congenital Heart Institute
Miami Children’s Hospital and Arnold Palmer Hospital
www.pediatricheartsurgery.com
 History
Our hybrid approach
to congenital heart
procedures evolved
from a shared
program goal of
reducing therapeutic
trauma.

Burke RP. Reducing the trauma of congenital heart

surgery.
Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu. 2001;4:216-28.
Predicates

To perform hybrid
procedures successfully,
there must be a strong
relationship between surgical
and medical subspecialties.
Program members must
adopt and share a common
philosophy – to use their
combined skills to reduce the
trauma of care for each
patient.
Common Pre-operative Considerations for
Aortic Hybrid Procedures
At our conferences, each patient presented for
therapy is discussed. We ask ourselves: Will a
hybrid approach decrease cumulative trauma?
We then identify the optimal setting (Operating
Room (OR) or Cath Lab or both)
to use the cath lab, you need mobile cardiopulmonary
bypass capability
We design an approach
 For patients with open chests, we can put sheaths directly into
the heart.
 For some patients, a carotid artery approach is optimal

For complex patients requiring other cardiac surgical repairs, a
Trans-aortic sheath is used.
Is the procedure ethical? – consent, IRB
Ethical standard: Would you use this approach for
your own child? I ask this of myself frequently.
 Teamwork
Synchronize the scheduling of the procedure so
that each team is available and on site
 Minimize total bypass and ischemic arrest times
Set each other up with optimal visualization and
access. We adopt the surgical assistant principle
and try to “make each other look good”.
Operating room and Cath lab staff will
enthusiastically participate in operations that are
efficient and effective.
Hybrid Aortic Arch Stent Insertion
Our Justification for this approach:
 We see 15-30% arch obstruction after Stage I palliation
for HLHS: the natural consequence of large patches
placed on small native aortas.

Surgical repairs of recurrent arch obstruction was
traumatic, particularly to the left phrenic nerve, resulting
in occasional diaphragm paralysis.
 Balloon angioplasty produced mixed results
 Transcatheter implantation of adult sized stents in
infants created significant vascular injury.
Anatomic Considerations
Arch obstruction
after Stage I is
usually distal,
circumferential
ductal tissue,
kinking, proximity
of left PA and
nerves.
You can see the
ductal tissue in
this arch by the
forceps, this
tissue contracts
over time.
Case Report 1. Hybrid Arch Stent
CLINICAL HISTORY: At the time of catheterization, Baby A was a
4-month-old born with initial diagnosis of hypoplastic left heart
syndrome. As a newborn, he underwent stage I Norwood palliation.
However, subsequently, he developed aortic arch obstruction. For
this, he underwent balloon angioplasty with a moderate
improvement.
He was scheduled for bidirectional cavopulmonary anastomosis and
was noted to have persistent aortic arch
obstruction.
We therefore planned hybrid implantation of an
adult-sized aortic stent.
HLHS: Initial Operative Image
Completed Stage 1 Reconstruction
Technique: Hybrid Arch Stent Insertion

At time of cavopulmonary anastomosis

Can be done On/off by-pass
Sheath in ascending aorta
Fluoroscopic guidance
Wire to descending aorta
Angiography via sheath
Stent delivery
Follow-up angiography
Remove sheath repair aorta
 SURGEON
CPB
CANULATION
VASCULAR ACCESS

INTERVENTIONAL
CARDIOLOGIST
STENT PLACEMENT
ANGIOPLASTY
Hospital Course: These are the daily picture
of this patient’s postoperative recovery.
Reoperations after arch stents: What does
the surgeon need to know?

Surgeons must
know which stents
OPERATIVE REPORT
DATE OF PROCEDURE: 05/19/2006
PREOPERATIVE DIAGNOSIS:
1. Hypoplastic left heart syndrome.
have the potential
to reach adult
2. Aortic arch obstruction status post stent insertion.
POSTOPERATIVE DIAGNOSIS:

size. We have to
1. Hypoplastic left heart syndrome.
2. Aortic arch obstruction status post stent insertion.

communicate this
PROCEDURE:
1. Fontan, extracardiac, fenestrated 19-mm Impra tube graft.
2. Aortic arch reconstruction with pericardial patch and opening of

well between the

stent.
SURGEON: Redmond P Burke, M.D.
ASSISTANT: Michael O'Brien, P.A. members of the
cardiac team, and
ANESTHESIA: General endotracheal.
INDICATIONS FOR OPERATION: The patient is a 5-year-old boy with
hypoplastic left heart syndrome who underwent an Norwood procedure as a
newborn followed by a bidirectional cavopulmonary anastomosis. He has
been treated with stents in his aortic arch and his left pulmonary
record the
artery. The left pulmonary artery stent has the capacity to reach adult
size. However, the aortic arch stent does not. The child therefore
will require opening of the stent at this operation. The child is
information in our
stable with no evidence of active infection at the time of surgery.
notes.
 Observations on Surgical Stent
Reoperations
It can be difficult to get distal control, low flow
bypass and intralumenal suction are necessary.
Within months stents will become embedded in
the aortic wall, they cannot be removed, but can
be split open with scissors and bent open with
some distal extension.
An onlay patch will work, but stent spikes may
cut suture. They can be trimmed with scissors.
No fresh aortic suture lines have ruptured or
bled acutely, or formed aneurysms, as a result of
hybrid stenting
Operative images: Arch Dissection after prior stent
placement
I’ve cut through the stent, and must make sure to
cut the final link, or the obstruction will persist.
This is the completed arch reconstruction with a pericardial
patch on top of the stented aorta. The stent is now
embedded in the back wall of the aorta.
The child’s postoperative course
was uncomplicated.
Clinical Review of Hybrid intra-
operative arch stent
Preliminary
experience in 3
patients (n = 74
patients having Stage
1 palliation )
Procedural Success
100%
Adult sized stents
placed without
residual gradients or
bleeding
 Disadvantages of Hybrid Stent
Implantation in the OR
 Sub-optimal angiographic imaging
Lack of biplane angiography
Limited C-arm angulation and quality
Direct surgical visualization limited
 We use intraoperative endoscopy to look inside the
repairs and ensure correct stent placement

Cardioscopy, TEE,
Direct Pressure Measurement
 Conclusions
Intra-operative Hybrid stent implantations
in the aorta can be performed safely, with
high precision, and high procedural
success rates.
Reoperations on arch stents are very
manageable
Redilations have been successful
Success with a hybrid approach depends
on a unified congenital heart team.
Thank you.