Transcatheter Stage I to Avoid Neonatal Surgeries in Newborns with HLHS and HLHC

Background: Therapy for hypoplastic left heart syndrome and complex (HLHS and HLHC, respectively) is still associated with significant morbidity and mortality. Our aim is to improve the outcome of these vulnerable patient groups by minimizing neonatal surgical trauma and postponing surgeries to later infancy. Here, we describe four patients who underwent a compassionate stage-1 procedure (S1P) using a novel, fully transcatheter approach.

Method: Currently, the transcatheter technique was performed in three prenatally diagnosed newborns with HLHS and one with HLHC with associated aortic atresia and inlet ventricular septal defect. Nonsurgical S1P was performed in four sedated, spontaneously breathing newborns with a median weight of 3,345 g and a median age of 5 days. First, an endoluminal pulmonary artery (PA) banding of the right and left PA was performed. For this purpose, microvascular plug (MVP) devices were manually modified to pulmonary flow restrictors (PFR's). PFR's were manually created by removing 1 of the 10 PTFE-covered end cells of the MVP with a scalpel. Thus, a perforation of approximately 3 to 4 mm was achieved. Following placement of bilateral PFR's, the arterial duct was stented with a self-expandable sinus-superflex-DS. At discharge, all patients received bisoprolol and clopidogrel. The parents were introduced in the surveillance, and all infants were closely followed by our out-clinic department aiming for a palliative or corrective stage II.

Results: Nonsurgical S1P were performed without mortality and complications. Taking the learning-curve into account, the median length of hospital stay was 16 days. During the interstage, three reinterventions were necessary, all of which were performed in advance. It included stenting of the atrial septum in one, dilatation of left-sided pulmonary vein (PV) stenosis in another, and a partial dilatation of the right PFR (3-mm coronary balloon) followed by placement of a coronary stent within a slowly developing aortic coarctation in the third patient with HLHC. Two patients already received a surgical comprehensive stage II at the age of 4 months. The removal of the PFR's went smoothly with only slight injury of the pulmonary intimal tissue and surgical reconstruction of the PAs before the Glenn anastomosis was uneventful.

Conclusion: Transcatheter S1P was successful in all four newborns. A close follow-up during interstage is mandatory as initial morphologies and functional status can suddenly change. A prospective, multicenter study is provided to compare the transcatheter with the hybrid approach.

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Artikel online veröffentlicht:
12. Februar 2022