Invited Commentary

Abstract

The use of the hybrid procedure for single-ventricle palliation has yet to find a niche in the surgical armamentarium. Optimal use of the hybrid procedure continues to be somewhat controversial. In this issue of The Annals of Thoracic Surgery, Sower and colleagues1Sower C.T. Romano J.C. Yu S. Lowery R. Pasquali S.K. Zampi J.D. Early and midterm outcomes in high-risk single-ventricle patients: hybrid vs Norwood palliation.Ann Thorac Surg. 2019; 108: 1849-1856Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar from Ann Arbor examine their experience and outcomes using the hybrid procedure in high-risk single-ventricle patients. The definition of high-risk patients in this study included prematurity less than 34 weeks’ gestation and a birth weight less than 2.5 kg. Additional factors included a restrictive or intact atrial septum, greater than moderate AV valve regurgitation, and genetic or extracardiac anomalies. The authors found that despite improved 30-day survival in hybrid patients (91% vs 66%), 1-year survival was similar between the hybrid and Norwood groups (46% vs 48%). They concluded that the use of the hybrid procedure in high-risk single-ventricle patients did not result in improved midterm survival. This study adds further evidence that the hybrid procedure is not effective in improving survival in single-ventricle patients, and in some ways it reflects our evolving experience with managing patients after a Norwood procedure. The hybrid procedure was initially conceived as a way to avoid the technical complexity of the Norwood procedure and postoperative management during the neonatal period. Results following the Norwood procedure have improved significantly as surgeons have gained experience with the procedure and centers have streamlined the postoperative care. As surgeons have gotten better with the Norwood procedure, the “learning curve” effect has been mitigated and mortality and survival rates are more reflective of the patient condition, rather than the procedure itself. As this study seems to demonstrate, high-risk patients remain at high risk because of factors related to the patient. Risk is no longer related to factors attributed to the procedure itself. Early and Midterm Outcomes in High-risk Single-ventricle Patients: Hybrid Vs Norwood PalliationThe Annals of Thoracic SurgeryVol. 108Issue 6PreviewAlthough overall outcomes have improved for single-ventricle patients, substantial morbidity and mortality remain for certain high-risk groups. The hybrid stage I procedure is an alternative to the Norwood operation for stage I palliation, but it remains unclear whether it is associated with improved outcomes in high-risk patients. Full-Text PDF