hybrid aortic arch stenting 2008
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Hybrid Procedures for Congenital Heart Repair:Hybrid Procedures for Congenital Heart Repair:
Aortic Arch StentingAortic Arch Stenting
Redmond P. Burke MD, FACS
Chief, Division of Cardiovascular Surgery
The Congenital Heart Institute
Miami Childrens Hospital and Arnold Palmer HospitalMiami Childrens Hospital and Arnold Palmer Hospitalwww.pediatricheartsurgery.comwww.pediatricheartsurgery.com
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PredicatesPredicates
To perform hybridTo perform hybrid
procedures successfully,procedures successfully,
there must be a strongthere must be a strong
relationship between surgicalrelationship between surgical
and medical subspecialties.and medical subspecialties.Program members mustProgram members must
adopt and share a commonadopt and share a common
philosophy to use theirphilosophy to use their
combined skills to reduce thecombined skills to reduce the
trauma of care for eachtrauma of care for each
patient.patient.
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Common Pre-operative Considerations forCommon Pre-operative Considerations for
Aortic Hybrid ProceduresAortic Hybrid Procedures
At our conferences, each patient presented forAt our conferences, each patient presented fortherapy is discussed. We ask ourselves: Will atherapy is discussed. We ask ourselves: Will ahybrid approach decrease cumulative trauma?hybrid approach decrease cumulative trauma?
We then identify the optimal setting (OperatingWe then identify the optimal setting (Operating
Room (OR) or Cath Lab or both)Room (OR) or Cath Lab or both)to use the cath lab, you need mobile cardiopulmonaryto use the cath lab, you need mobile cardiopulmonary
bypass capabilitybypass capability
We design an approachWe design an approach For patients with open chests, we can put sheaths directly intoFor patients with open chests, we can put sheaths directly into
the heart.the heart. For some patients, a carotid artery approach is optimalFor some patients, a carotid artery approach is optimal For complex patients requiring other cardiac surgical repairs, aFor complex patients requiring other cardiac surgical repairs, a
Trans-aortic sheath is used.Trans-aortic sheath is used.
Is the procedure ethical? consent, IRBIs the procedure ethical? consent, IRB
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Ethical standard: Would you use this approach forEthical standard: Would you use this approach for
your own child? I ask this of myself frequently.your own child? I ask this of myself frequently.
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TeamworkTeamwork
Synchronize the scheduling of the procedure soSynchronize the scheduling of the procedure so
that each team is available and on sitethat each team is available and on site Minimize total bypass and ischemic arrest timesMinimize total bypass and ischemic arrest times
Set each other up with optimal visualization andSet each other up with optimal visualization andaccess. We adopt the surgical assistant principleaccess. We adopt the surgical assistant principle
and try to make each other look good.and try to make each other look good.
Operating room and Cath lab staff willOperating room and Cath lab staff willenthusiastically participate in operations that areenthusiastically participate in operations that are
efficient and effective.efficient and effective.
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Hybrid Aortic Arch Stent InsertionHybrid Aortic Arch Stent Insertion
Our Justification for this approach:Our Justification for this approach: We see 15-30% arch obstruction after Stage I palliationWe see 15-30% arch obstruction after Stage I palliation
for HLHS: the natural consequence of large patchesfor HLHS: the natural consequence of large patches
placed on small native aortas.placed on small native aortas.
Surgical repairs of recurrent arch obstruction wasSurgical repairs of recurrent arch obstruction was
traumatic, particularly to the left phrenic nerve, resultingtraumatic, particularly to the left phrenic nerve, resulting
in occasional diaphragm paralysis.in occasional diaphragm paralysis.
Balloon angioplasty produced mixed resultsBalloon angioplasty produced mixed results
Transcatheter implantation of adult sized stents inTranscatheter implantation of adult sized stents in
infants created significant vascular injury.infants created significant vascular injury.
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Anatomic ConsiderationsAnatomic Considerations
Arch obstructionArch obstructionafter Stage I isafter Stage I isusually distal,usually distal,circumferentialcircumferentialductal tissue,ductal tissue,
kinking, proximitykinking, proximityof left PA andof left PA andnerves.nerves.
You can see theYou can see theductal tissue inductal tissue in
this arch by thethis arch by theforceps, thisforceps, thistissue contractstissue contractsover time.over time.
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Case Report 1. Hybrid Arch StentCase Report 1. Hybrid Arch Stent
CLINICAL HISTORY: At the time of catheterization, Baby A was aCLINICAL HISTORY: At the time of catheterization, Baby A was a4-month-old born with initial diagnosis of hypoplastic left heart4-month-old born with initial diagnosis of hypoplastic left heartsyndrome. As a newborn, he underwent stage I Norwood palliation.syndrome. As a newborn, he underwent stage I Norwood palliation.However, subsequently, he developed aortic arch obstruction. ForHowever, subsequently, he developed aortic arch obstruction. Forthis, he underwent balloon angioplasty with a moderatethis, he underwent balloon angioplasty with a moderateimprovement.improvement.
He was scheduled for bidirectional cavopulmonary anastomosis andHe was scheduled for bidirectional cavopulmonary anastomosis andwas noted to have persistent aortic archwas noted to have persistent aortic arch
obstruction.obstruction.
We therefore planned hybrid implantation of anWe therefore planned hybrid implantation of anadult-sized aortic stent.adult-sized aortic stent.
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HLHS: Initial Operative ImageHLHS: Initial Operative Image
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Completed Stage 1 ReconstructionCompleted Stage 1 Reconstruction
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Technique: Hybrid Arch Stent InsertionTechnique: Hybrid Arch Stent Insertion
At time of cavopulmonary anastomosisAt time of cavopulmonary anastomosis
Can be done On/off by-passCan be done On/off by-pass
Sheath in ascending aortaSheath in ascending aorta
Fluoroscopic guidanceFluoroscopic guidance
Wire to descending aortaWire to descending aorta
Angiography via sheathAngiography via sheath
Stent deliveryStent delivery
Follow-up angiographyFollow-up angiography
Remove sheath repair aortaRemove sheath repair aorta
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SURGEON
CPB
CANULATION
VASCULAR ACCESS
INTERVENTIONAL
CARDIOLOGIST
STENT PLACEMENT
ANGIOPLASTY
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Hospital Course: These are the daily pictureHospital Course: These are the daily picture
of this patients postoperative recovery.of this patients postoperative recovery.
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Reoperations after arch stents: What doesReoperations after arch stents: What does
the surgeon need to know?the surgeon need to know?
OPERATIVE REPORTOPERATIVE REPORT
DATE OF PROCEDURE: 05/19/2006DATE OF PROCEDURE: 05/19/2006
PREOPERATIVE DIAGNOSIS:PREOPERATIVE DIAGNOSIS:1. Hypoplastic left heart syndrome.1. Hypoplastic left heart syndrome.2. Aortic arch obstruction status post stent insertion.2. Aortic arch obstruction status post stent insertion.
POSTOPERATIVE DIAGNOSIS:POSTOPERATIVE DIAGNOSIS:1. Hypoplastic left heart syndrome.1. Hypoplastic left heart syndrome.2. Aortic arch obstruction status post stent insertion.2. Aortic arch obstruction status post stent insertion.
PROCEDURE:PROCEDURE:1. Fontan, extracardiac, fenestrated 19-mm Impra tube graft.1. Fontan, extracardiac, fenestrated 19-mm Impra tube graft.2. Aortic arch reconstruction with pericardial patch and opening of2. Aortic arch reconstruction with pericardial patch and opening ofstent.stent.
SURGEON: Redmond P Burke, M.D.SURGEON: Redmond P Burke, M.D.
ASSISTANT: Michael O'Brien, P.A.ASSISTANT: Michael O'Brien, P.A.
ANESTHESIA: General endotracheal.ANESTHESIA: General endotracheal.
INDICATIONS FOR OPERATION: The patient is a 5-year-old boy withINDICATIONS FOR OPERATION: The patient is a 5-year-old boy withhypoplastic left heart syndrome who underwent an Norwood procedure as ahypoplastic left heart syndrome who underwent an Norwood procedure as anewborn followed by a bidirectional cavopulmonary anastomosis. He hasnewborn followed by a bidirectional cavopulmonary anastomosis. He hasbeen treated with stents in his aortic arch and his left pulmonarybeen treated with stents in his aortic arch and his left pulmonaryartery. The left pulmonary artery stent has the capacity to reach adultartery. The left pulmonary artery stent has the capacity to reach adultsize. However, the aortic arch stent does not. The child thereforesize. However, the aortic arch stent does not. The child thereforewill require opening of the stent at this operation. The child iswill require opening of the stent at this operation. The child isstable with no evidence of active infection at the time of surgery.stable with no evidence of active infection at the time of surgery.
Surgeons must
know which stents
have the potential
to reach adultsize. We have to
communicate this
well between the
members of thecardiac team, and
record the
information in our
notes.
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Observations on Surgical StentObservations on Surgical Stent
ReoperationsReoperationsIt can be difficult to get distal control, low flowIt can be difficult to get distal control, low flowbypass and intralumenal suction are necessary.bypass and intralumenal suction are necessary.
Within months stents will become embedded inWithin months stents will become embedded inthe aortic wall, they cannot be removed, but canthe aortic wall, they cannot be removed, but can
be split open with scissors and bent open withbe split open with scissors and bent open withsome distal extension.some distal extension.
An onlay patch will work, but stent spikes mayAn onlay patch will work, but stent spikes maycut suture. They can be trimmed with scissors.cut suture. They can be trimmed with scissors.
No fresh aortic suture lines have ruptured orNo fresh aortic suture lines have ruptured orbled acutely, or formed aneurysms, as a result ofbled acutely, or formed aneurysms, as a result ofhybrid stentinghybrid stenting
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Operative images: Arch Dissection after prior stentOperative images: Arch Dissection after prior stent
placementplacement
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Ive cut through the stent, and must make sure toIve cut through the stent, and must make sure to
cut the final link, or the obstruction will persistcut the final link, or the obstruction will persist..
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The childs postoperative courseThe childs postoperative course
was uncomplicated.was uncomplicated.
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Clinical Review of Hybrid intra-Clinical Review of Hybrid intra-
operative arch stentoperative arch stent
PreliminaryPreliminaryexperience in 3experience in 3patients (n = 74patients (n = 74patients having Stagepatients having Stage1 palliation )1 palliation )
Procedural SuccessProcedural Success100%100%
Adult sized stentsAdult sized stentsplaced withoutplaced withoutresidual gradients orresidual gradients orbleedingbleeding
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Disadvantages of Hybrid StentDisadvantages of Hybrid Stent
Implantation in the ORImplantation in the OR
Sub-optimal angiographic imagingSub-optimal angiographic imaging
Lack of biplane angiographyLack of biplane angiography
Limited C-arm angulation and qualityLimited C-arm angulation and quality
Direct surgical visualization limitedDirect surgical visualization limited
We use intraoperative endoscopy to look inside theWe use intraoperative endoscopy to look inside the
repairs and ensure correct stent placementrepairs and ensure correct stent placement
Cardioscopy, TEE,Direct Pressure Measuremen
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ConclusionsConclusions
Intra-operative Hybrid stent implantationsIntra-operative Hybrid stent implantationsin the aorta can be performed safely, within the aorta can be performed safely, withhigh precision, and high proceduralhigh precision, and high procedural
success rates.success rates.Reoperations on arch stents are veryReoperations on arch stents are verymanageablemanageable
Redilations have been successfulRedilations have been successfulSuccess with a hybrid approach dependsSuccess with a hybrid approach dependson a unified congenital heart team.on a unified congenital heart team.
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Thank you.Thank you.