Congenital: Hypoplastic Left Heart Syndrome| Volume 164, ISSUE 5, P1291-1303.e6, November 2022

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Hybrid strategy in neonates with ductal-dependent systemic circulation and multiple risk factors



      The study objective was to analyze outcomes of the hybrid strategy for ductal-dependent systemic circulation consisting of bilateral pulmonary artery banding with or without ductal stenting followed by delayed Norwood-type palliation or comprehensive stage II operation in high-risk neonates.


      A retrospective analysis was performed between December 2017 and March 2021. Thirty high-risk neonates underwent palliation with bilateral pulmonary artery banding: 11 with prostaglandin therapy and 19 with ductal stenting. Median (range) age and body weight of patients at hybrid stage I were 3 days (0-43) and 2.9 kg (1.1-4.2), respectively. Operative and interstage mortality, morbidity, and reintervention rates were assessed.


      Overall survival was 70% (21/30) at a median follow-up time of 9 months (range, 0-37) from hybrid stage I. Operative survival for hybrid stage I was 90% (27/30), of which 2 patients received palliative care, and there was 1 interstage death (4%, 1/27). After hybrid stage I, 37% of patients had a reintervention, and 3% (n = 1) used extracorporeal membrane oxygenation before the next stage of repair. Five patients are awaiting second-stage operation, and 9 patients are awaiting Fontan completion.


      High-risk neonates with hypoplastic left heart syndrome or its variants can be successfully palliated using the hybrid strategy and bridged to a delayed Norwood or comprehensive stage II operation with satisfactory survival. This operative approach is a promising alternative pathway for neonates deemed to be high risk due to multiple preoperative risk factors.

      Graphical abstract

      Key Words

      Abbreviations and Acronyms:

      BiV (biventricular), BDG (bidirectional Glenn), BPAB (bilateral pulmonary artery banding), CICU (cardiac intensive care unit), CSII (comprehensive stage II), ECMO (extracorporeal membrane oxygenation), HLHS (hypoplastic left heart syndrome), MRI (magnetic resonance imaging)
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      • Notice of Correction
        The Journal of Thoracic and Cardiovascular SurgeryVol. 165Issue 1
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          Re: Ceneri NM, Desai MH, Tongut A, Ozturk M, Ramakrishnan K, Staffa SJ, et al; Children's National Hospital Hybrid Working Group. Hybrid strategy in neonates with ductal-dependent systemic circulation and multiple risk factors. J Thorac Cardiovasc Surg. 2022;164:1291-303.
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      • Commentary: Palliation pit stop
        The Journal of Thoracic and Cardiovascular SurgeryVol. 164Issue 5
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          Despite improvements in surgical technique and medical care, 1-year transplant-free survival rates for newborns with hypoplastic left heart syndrome continue to approximate 70%.1 Bilateral pulmonary artery banding with ductal stenting (hybrid palliation) was initially developed to alter this paradigm by avoiding cardiopulmonary bypass and circulatory arrest in the neonatal period.2 Reported results for this strategy are either equivalent or inferior to Norwood.3 Most centers use the hybrid procedure selectively for high-risk patient populations.
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