Anesthetic management of the hybrid stage 1 procedure for hypoplastic left heart syndrome (HLHS)

Abstract

Patients undergoing the hybrid procedure have relatively stable intraoperative and early postoperative hemodynamics. The procedure is performed without cardiopulmonary bypass (CPB) and with minimal narcotic and anesthetic exposure. Patients typically do not require blood transfusions or inotropic support and are extubated at either the end of the procedure or within 24 h of ICU admission. In our experience, the anesthetic management of patients undergoing the hybrid procedure is straightforward and requires relatively few interventions when compared to traditional neonatal surgical repairs. Deferring the risks of anesthesia, CPB, hypothermic circulatory arrest, and prolonged postoperative sedation may yield developmental advantages to patients born with HLHS.

Anesthesia for Cardiac Surgery in Neonates

“…Deferring the risks associated with the Norwood operation to a later time in infancy, as allowed by a hybrid procedure, can offer potential advantages to the neonate. Although caring for a neonate with a critical lesion, such as HLHS, outside the typical surgical setting can present major challenges, a report on the anesthetic management of neonates undergoing the hybrid procedure documented relatively stable intraoperative and early postoperative hemodynamics [ 83 ]. In addition, this experience indicated that most neonates did not require blood transfusions or inotropic support and performing endotracheal extubation was feasible either at the end of the procedure or soon after the infant was admitted to intensive care.…”

Anesthesia for high‐risk procedures in the catheterization laboratory

“…Continuous monitoring of the right upper extremity pressure and cerebral perfusion by means of a right radial arterial line and a cerebral oximetry probe is recommended. These monitors can help not only the clinical management during the hybrid procedure, but can also detect adverse events such as retrograde arch obstruction during ductus stent deployment …”

“…46,47 Despite the initial hopes that avoiding cardiopulmonary bypass and deep hypothermic circulatory arrest can decrease mortality, it is thought that this is overshadowed by the potential diastolic run off from the stented ductus jeopardizing coro- These monitors can help not only the clinical management during the hybrid procedure, but can also detect adverse events such as retrograde arch obstruction during ductus stent deployment. 48…”

Anesthetic Considerations in Infants With Hypoplastic Left Heart Syndrome

“…The study authors report that the patients had stable intraoperative and early postoperative hemodynamics. 41 This hybrid palliation procedure defers the risks of anesthesia, CPB, hypothermia, and prolonged postoperative sedation and may confer developmental advantages to patients born with HLHS who are known to have abnormal brain development. 39,42 However, current literature does not indicate better outcomes with this hybrid approach beyond the second stage palliated Glenn surgery for HLHS.…”