ISSN 0326-646X





Sumario Vol. 43 - Nº 1 Enero - Marzo 2014

Hybrid procedure with balloon catheter in patients
with pulmonary atresia and preserved interventricular septum

Luis E. Marcano, Francisco J. Ozores, José A. Seijas, Ernesto Cotilla

Cardiocentro Pediátrico "William Soler". La Habana, Cuba
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Recibido 23-OCT-2013 – ACEPTADO después de revisión el 19-NOVIEMBRE de 2013.

The authors declare not having a conflict of interest.
Rev Fed Arg Cardiol. 2014; 43(1): 39-41

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In Cardiology and Pediatric Cardiovascular Surgery, hybrid techniques are new and challenging procedures, since they interlace disciplines, and combine the ability and experience of surgeons and cardiologists. The hybrid decompression of the right ventricle in patients with pulmonary valvular atresia and intact ventricular septum, emerge like an alternative to the percutaneous procedures. The technique used in a 5-day-old girland 2.9 kg is described. The postoperative course was uneventful, she received mechanical ventilation for 16 hours and was discharged from hospital 7 days later. After 6 months of operated, the anterograde pulmonary flow is adequate, without obstruction and oxygen saturation rise of 90%.
The hybrid dilatation with balloon catheter in the pulmonary valvular atresia with intact interventricular septum is a feasible, safe and efficacious alternative in selected patients.

Key words: Pulmonary atresia. Hybridprocedures. Valvuloplasty. .



The management strategy for pulmonary atresia with preserved interventricular septum depends mostly, from the morphological features of the right ventricle [1]. In the cases with light or moderate hypoplasia, early decompression increases the probability of biventricular repair [1,2]. The percutaneous procedures by interventionist catheterization are the first choice in patients with a favorable anatomy: open infundibulum, membranous valve atresia and a proper tricuspid size. However, this therapeutic modality is associated to a high rate of failures and a mortality of 4% to 50% [1]. The main complications are right ventricular perforation with cardiac tamponade and severe pulmonary regurgitation [1,2].

In cardiology and pediatric cardiovascular surgery, the hybrid techniques are new and challenging procedures, since they mix disciplines, and combine the ability and expertise of surgeons and hemodynamists. Hybrid decompression of the right ventricle in patients with pulmonary atresia and preserved interventricular septum, emerged as an alternative to percutaneous procedures, to decrease complications and increase the rate of success [3,4].


A 5-day old girl, with 2.5 kg of weight, presented with a diagnosis of membranous pulmonary atresia, preserved interventricular septum, tripartite right ventricle and 2 mm patent ductus arteriosus. In interventionist catheterization the pulmonary valve could not be perforated with the metal guide or radiofrequency. Median sternotomy was conducted and through right ventricular infundibulum, 2 cm below the pulmonary annulus, the valve was punctured and pierced with a 16 G needle; the metal guide, the dilator, the introducer sheath and the balloon catheter were introduced, with the latter being insufflated twice without difficulty (Figure 1).

Figure 1. Intraoperative view. The introducer sheath is observed through the right ventricular infundibulum and the pulmonary artery trunk dilated by balloon catheter (10 Fr diameter) insufflated within.


Arterial oxygen saturation remained around 60% with no pressure gradient or organ obstruction in the right ventricular outlet being verified in echocardiography. It was considered that due to the great hypertrophy in the mentioned ventricle and its low distensibility, it was not capable to supporting pulmonary circulation effectively at the time. Ductus arteriosus and modified right Blalock Taussig pulmonary systemic fistula ligation was made, with a 3 mm polytetrafluorethylene tube.

The patient evolved satisfactorily, received mechanical ventilation for 16 hours and stayed in the hospital for 7 days. Six months after the operation, she keeps a good pulmonary anterograde flow, without obstruction in the right ventricular outlet and normally functioning pulmonary systemic fistula (Figure 2). Arterial oxygen saturation greater than 90%.

Figure 2. Echocardiographic view of parasternal short axis where the anterograde flow by the right ventricular outflow tract (RVOT) is seen in blue and Blalock Taussig pulmonary systemic fistula (BTF) in red. AO: Aorta.
Right atrium.


Hybrid procedures present several advantages in regard to interventionist or surgical procedures: they prevent the aggression produced by cardiopulmonary bypass and thus, decrease mechanical ventilation and hospital stay times; they prevent damaging peripheral vascular structures; decrease the risk of right ventricular perforations, tricuspid valve tearing, arrhythmias and cardiac arrest [1-3]. Burke et al [2], in their experience with radiofrequency, pose that the angle of access into the pulmonary valve is much more favorable when the intervention is made through the right ventricle, which achieves a greater catheter and devices stability, and it also reduces the chance of perforations. During the operation, the surgeon has a more clear image to make a puncture in the central area of the valve, and thus, post-operative valve regurgitation [1].

Even in the patients in whom interventionist procedures are successful, the need for surgical interventions in the neonatal period, whether by pulmonary systemic fistulae or right ventricular outflow tract reconstruction, could be as high as 75% [1,4]. However, the Blalock Taussig fistula in the same surgical time, prevents severe hypoxemia, new interventions and the adverse effects of the extended use of prostaglandin E1. A recent systematic review showed a similar post-operative evolution in the mid term in relation to the success of decompression, in the patients treated with hybrid techniques as in those intervened by surgery and extracorporeal circulation. Nevertheless, in those it was possible to prevent in 100% of the cases, cardiopulmonary bypass and the adverse effects of it [4].

It has been pointed out too, that hybrid techniques are easier to implement and promote than interventionist catheterization [1,2]. All the advantages acquire a greater relevance in newborn babies with low body weight and it is expected that future investigations will determine the effect of these combined options  not just on morbi-mortality, but on the reduction of surgical times, contrast amount and exposition to radiations [2,4].

Although it is necessary to individualize every case, the hybrid dilatation with balloon catheter in patients with pulmonary atresia and preserved interventricular septum may be considered a feasible, efficient and safe alternative to the standard treatment techniques by interventionist catheterization or by surgery, and in selected patients, constitute the optimal therapeutic strategy.



  1. Li S, Chen W, Zhang Y, et al. Hybrid Therapy for Pulmonary Atresia with Intact Ventricular Septum. Ann Thorac Surg 2011; 91: 1467-72.
  2. Burke RP, Hannan RL, Zabinsky JA, et al. Hybrid Ventricular Decompression in Pulmonary Atresia with Intact Septum. Ann Thorac Surg 2009; 88:688–9.
  3. Zhang H, Li SJ, Li YQ, et al. Hybrid procedure for the neonatal management of pulmonary atresia with intact ventricular septum. J Thorac Cardiovasc Surg 2007; 133: 1654-6.
  4. Zampi JD, Hirsch-Romano JC, Goldstein BH, et al. Hybrid Approach for Pulmonary Atresia with Intact Ventricular Septum: Early Single Center Results and Comparison to the Standard Surgical Approach. Catheter Cardiovasc Interv 2013 Aug 31. doi: 10.1002/ccd.25181. [Epub ahead of print].


Publication: March 2014

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