The current role of hybrid procedures in the stage 1 palliation of patients with hypoplastic left heart syndrome.

Hypoplastic left heart syndrome is a relatively common cardiac malformation, accounting for 4-9% of children born with congenital heart disease. Since 1981 the mainstay of treatment has been the Norwood series of operations which have been variously modified, most recently using an RV-PA conduit (Sano shunt). With these surgical modifications and with increased experience in perioperative care survival for the surgical approach to completion of stage 2 palliation has improved to 70-80%. However, in 1997 when surgical results were poorer, interventional cardiologists explored the possibility of hybrid palliation of these children using a combined transluminal and closed surgical technique as it was perceived this would be less traumatic. Poor initial results caused many to discontinue this approach but some persevered, and with increasing experience survival to completion of stage 2 following hybrid palliation is now 50-80%. Although these results may superficially appear to be poorer than for surgery, it must be observed that increasingly the hybrid approach has been used by many groups as palliation for the highest risk cases (particularly small size and adverse cardiac factors). This review therefore considers what is the optimal management of children with hypoplastic left heart syndrome currently, and, specifically, what is the role for the hybrid approach in palliation of patients with hypoplastic left heart syndrome?