Hybrid procedures: The past, present or future?

If you open almost any pediatric cardiology journal today, you’ll find articles referring to “hybrid” procedures. With hybrid procedures increasingly becoming a part of common practice, they seem to be the future of interventional cardiology. To further elucidate this important topic, I’ve provided and answered some of the most common questions clinicians ask about hybrid procedures today.

What is a hybrid procedure?

Simply put, a hybrid procedure is the use of procedural techniques from different specialties to accomplish a shared procedural goal. In cardiology, this typically involves the combination of surgical and catheter-based techniques.

Notice that my definition does not mention any specific diagnosis, and the outcome measure of “accomplish a procedural goal” is pretty vague. There isn’t even the mention of a particular specialty. The reason for this is simple: Hybrid procedures aren’t just procedures; they are a concept of thinking outside the box and using all of the available tools — not just those within a particular specialty’s toolbox — to provide solutions to difficult problems. They are an opportunity to collaborate and do something truly novel, which doesn’t always mean doing something complex.

Jeffrey D. Zampi

Are hybrid procedures new?

No. In fact the first description of what we would now call a hybrid procedure was in 1972 (even though the word hybrid was never used). In the paper by Bhati and colleagues, surgical closure of a patent ductus arteriosus during open heart operations for other intracardiac lesions was facilitated by placing a balloon catheter across the ductus from an incision in the pulmonary artery. The authors commented that in the three patients in whom this technique was used, they were “impressed by the simplicity and quickness of the procedure” and there were no complications associated with this technique.

What are the potential advantages of hybrid procedures?

For cardiac patients, some of the potential advantages include:

Avoiding cardiopulmonary bypass;
Lowering procedural complication rates;
Shortening procedural times and minimizing technical difficulty by providing direct access to the heart;
Being able to treat smaller infants than could be done with traditional surgical or catheter-based techniques.

What are the current applications of hybrid procedures?

Although not an all-inclusive list, some of the current applications of hybrid procedures include:

Hypoplastic left heart syndrome (stage I hybrid procedure — bilateral pulmonary artery band placement, ductus arteriosus stent implantation, and atrial septal stent implantation or septoplasty);
Pulmonary atresia with intact ventricular septum (perventricular pulmonary valve perforation and balloon valvuloplasty);
Ventricular septal defect (VSD; perventricular VSD device closure);
Atrial septal defect (ASD; peratrial ASD device closure);
Branch pulmonary artery stenosis (intra-operative pulmonary artery stent implantation);
CAD (myocardial revascularization).

What is the future of hybrid procedures?

This is where you come in. Do you have a difficult procedural dilemma and wish there was a better approach? I encourage you to collaborate and look for creative solutions. And don’t stop within your office or department. What is that neurosurgeon or interventional radiologist doing, and how can you apply that to your patient? If you are a pediatric cardiologist, don’t skip over all those “adult” articles in the next Catheterization and Cardiovascular Interventions that comes across your desk. Go to a Grand Rounds given by someone not in your field of expertise. Attend regional and national conferences and sit next to someone you don’t know at a session that is outside of your subspecialty. Think of hybrid procedures as a concept and you may be surprised what you come up with.

Further reading

For more information about various hybrid procedures, including their potential benefits and risks, please check out some of these articles listed below.

Reference:

Bhati BS. J Thorac Cardiovasc Surg. 1972;63:820-826.

For more information:

Bacha EA. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu. 2007;146-150.

Galantowicz M. Pediatr Cardiol. 2005;26:190-199.

Hjortdal VE. Eur J Cardiothorac Surg. 2002;22:885-890.

Jeffrey D. Zampi, MD, is an interventional pediatric cardiologist and cardiac intensivist at the University of Michigan Congenital Heart Center and is an assistant professor of pediatrics at the University of Michigan, Ann Arbor. His areas of expertise are in interventional pediatric cardiology and cardiac critical care.
Disclosure: Zampi reports no relevant financial disclosures.