Introduction

The three pillars of the treatment of congenital heart disease are conservative (mainly pharmacological) treatment, heart catheter intervention and surgery. Nowadays many of the more simple heart defects may be treated by catheter intervention, avoiding surgery and producing equally good or sometimes even better results.

In catheter interventions the catheter, a thin flexible tube, is introduced into a blood vessel in the groin and advanced as far as the heart, under X-ray monitoring. In the heart the catheter is used to enlarge narrow sites (balloon catheter), to place stents (vessel supports) or to close septal defects with occluders. Generally the patients can be dscharged from hospital on the next day or the day after.

With complex heart defects surgery is still essential. In severe cases, several surgical or interventional procedures are necessary during the patient's lifetime, so that the cardiovascular system remains stable.

Methods

To make the treatment procedures as effective as possible and only as invasive as necessary, in particular cases so-called hybrid treatment is performed. This combines the catheter intervention and the operation and is carried out either by an operation team in the heart catheterization laboratory or by a catheter intervention team in the operating room.

At the DHZB this kind of procedure has been performed since March 2008 in a special operating room. This combines all the equipment needed for complex heart surgery using the heart-lung machine with the facilities of a modern heart catheterization laboratory for complex interventional procedures.

Current areas of application

The main areas of application of hybrid surgery are currently pulmonary valve replacement and the interventional treatment of pulmonary artery stenoses. Surgical valve replacement is combined with stent implantation under direct vision. The advantage is that the procedure is much shorter since the stenoses can be treated interventionally; at the same time, the intervention is made much easier by direct access to the vessel. Thus the patient undergoes only one procedure.

Palliation in patients with hypoplastic left heart syndrome

In children with this severe heart defect, three operations are necessary in the first years of life. The first and most complex operation must take place within the first few days after birth. As an alternative, hybrid therapy makes the first operation easier. It is not necessary to connect the child to the heart/lung machine; instead the pulmonary arteries are banded and the ductus arteriosus is stented by intervention. Direct access to the pulmonary artery makes the work of the interventionist easier.

Closure of large muscular ventricular septal defects in infants

This procedure is often very difficult when performed by surgery alone, as the position of the ventricular defects makes them difficult to access. Pure catheter intervention carries a high risk, as the catheters are relatively large. In the hybrid procedure the chest is opened. Under ultrasound monitoring (Fig. 1) the catheter is introduced into the heart through a tiny entry canal (Fig, 2) and advanced to reach the septal defect. Next an occluder is introduced via the catheter and positioned in the beating heart so as to close the defect (Figs. 3 and 4). Use of the heart/lung machine is not necessary. When the catheter has been removed, the surgeon stitches up the entry canal and closes the chest.

Conclusion

By combining surgical and catheter intervention techniques in a single sitting, the number of heart procedures and their duration and complexity can be reduced.

Address for correspondence:

Dr. med. Peter Ewert
Dept. for Congenital Heart Disease /
Pediatric Cardiology
Deutsches Herzzentrum Berlin
Augustenburger Platz 1
13353 Berlin
Email : ewert@dhzb.de
Tel. :  +49 30 4593 0
Fax : +49 30 4593 1003