Tag Archive for: Yerebakan

Cayden rides a horse with her father

Earliest hybrid HLHS heart surgery kids thrive 5 years later

Cayden rides a horse with her father

Five years ago, Cayden was born 6 weeks early weighing less than four pounds and at risk of dying from her critical congenital heart disease. Today, she’s a happy five-year-old who is excited to start kindergarten this fall.

Five years ago, Cayden was born 6 weeks early weighing less than four pounds and at risk of dying from her critical congenital heart disease. Today, she’s a happy five-year-old who is excited to start kindergarten this fall.

Early diagnosis of her hypoplastic right ventricle, double inlet left ventricle and critical coarctation of the aorta allowed for the team at Children’s National Hospital to create a careful plan for safe delivery and to offer an innovative hybrid HLHS surgical approach at the hospital within 24 hours after she was born.

“Truly in my own heart, I do not believe Cayden would be alive today without Dr. Yerebakan and those early hybrid procedures,” says her mom, Casey.

Can Yerebakan, M.D., associate chief of Cardiac Surgery, and Joshua Kanter, M.D., director of Interventional Cardiology, have performed more of these hybrid procedures together at Children’s National than just about anywhere else in the United States. And they are the only team in the country using a special toothpick-sized flexible stent in the ductus. They worked directly with the U.S. Food and Drug Administration to bring these right-sized tiny stents to the U.S. from Europe.

Cayden was one of the first babies to benefit from this cutting-edge approach. In the five-plus years since then, more than 50 high-risk babies, some born as early as 28 weeks of gestation or weighing as little as 2 pounds at birth, have also benefited from hybrid procedures. Soon, the team will start performing hybrid procedures with catheters only, preventing an incision in the chest. This will allow the smallest babies to get the care they need with fewer open-chest procedures.

Read the rest of Cayden’s story here.

Yves d’Udekem, M.D., Ph.D.,

Evidence and expertise drive cardiac surgery innovation at Children’s National Hospital

Yves d’Udekem, M.D., Ph.D.,

“Our goal is to do the difficult and the impossible,” says Yves d’Udekem, M.D., Ph.D.

“Our goal is to do the difficult and the impossible,” says Yves d’Udekem, M.D., Ph.D., chief of Cardiac Surgery at Children’s National Hospital.

Dr. d’Udekem and the cardiac surgeons at Children’s National apply technical skill and expertise to offer renewed hope for the highest risk children with critical congenital heart disease, including those with single ventricle anomalies like hypoplastic left heart syndrome.

“When families have nowhere else to turn, they can turn to us,” he adds.

Why it matters

The cardiac surgery team has welcomed families from across the United States and around the world who seek experts in the care of these critical heart conditions. Their experience is building an important evidence base for better surgical approaches that will improve long-term outcomes for children with many different types of congenital heart disease, but especially for single ventricle conditions.

Innovation in cardiac surgery

  • Hybrid surgical strategy: Cardiac Surgeon Can Yerebakan, M.D., and Interventional Cardiology Director Joshua Kanter, M.D., are national leaders in the use of a hybrid surgical strategy for high-risk infants with single ventricle heart conditions. They can perform this procedure on babies as small as 1.1 kilograms. It allows critical time for the lungs and other organs to recover and get stronger after birth before the child undergoes more invasive procedures.
  • New uses for artificial hearts: d’Udekem showed proof-of-concept for the use of an artificial heart to give a child with a single ventricle the time for their own heart to recover rather than being transplanted. In this case, the child was supported by a left-ventricle assist device (LVAD) long term. As their own heart recovered, surgeons then performed successful procedures that seemed impossible to perform before.
  • Novel complex pulmonary artery reconstruction: Children’s National performs the most complex lobar and sub-lobar pulmonary artery reconstruction for children with complex pulmonary stenosis. Cardiac Surgeon Manan Desai, M.D., says the approach leverages interventional cardiac imaging and precision surgical techniques to correct stenosis in smaller lung arteries. This helps establish better right-sided pressure in the heart and likely reduces the chance of heart failure down the road.
  • Pediatric-focused advanced lung care and transplant: Children’s National is poised to become one of only a few locations in the United States to offer comprehensive care for children with complex lung conditions. In 2024, Cardiac Surgeon Aybala Tongut, M.D., will begin performing pediatric lung transplants as part of the hospital’s Advanced Lung Disease Program focused on the unique needs of children.

Children’s National leads the way

“It’s time to combine firsthand expertise and long-term outcomes from decades of congenital heart surgical procedures to refine our surgical techniques,” says Dr. d’Udekem. “We need to ensure patients with congenital heart disease, especially those with single ventricle heart defects, can thrive long term.”
animation showing MRI cardiac imaging

Soon, the Children’s National team plans to re-examine the effectiveness of different techniques for the Fontan procedure. They’ll compare an extracardiac approach against the older lateral tunnel procedure to determine how best to reduce long-term pressure on the heart by creating larger conduits and improving blood flow.

More education is needed to ensure valve repairs for children with congenital heart disease, including single ventricle conditions, which have a high rate of failure and require reoperation, are as successful as can be. The goal is to avoid the need for reoperation or replacement procedures. This is why Children’s National recently hosted the inaugural Valve Repair Symposium. It featured practical cases illustrated with intraoperative video, echocardiography and MR images to bring critical knowledge about pediatric heart valve repair to more people in the field.

chest x-ray showing placement of tiny pacemaker

First infants in the U.S. with specially modified pacemakers show excellent early outcomes

chest x-ray showing placement of tiny pacemaker

Chest/abdominal x-ray of neonate receiving a modified pediatric-sized implantable pulse generator, demonstrating epicardial suture-on bipolar lead and pulse generator in the upper abdominal pocket.

In 2022, five tiny, fragile newborns with life-threatening congenital heart disease affecting their heart rhythms were the first in the United States to receive a novel modified pacemaker generator to stabilize their heart rhythms within days of birth.

An article in the journal Heart Rhythm assesses the outcomes to date for the infants who received pacemakers that were modified to work better in the smallest children who need them. The authors, including first author Charles Berul, M.D., chief of Cardiology at Children’s National Hospital, share that after following for between 6 and 9 months, “early post-operative performance of this device has been excellent.”

The big picture

Even the tiniest pacemakers and defibrillators on the market today aren’t small enough for infants and young children with heart rhythm abnormalities. So, for several years, Dr. Berul and colleagues at several other institutions have collaborated to adapt existing pacemakers, including the Medtronic Micra leadless pacing system, for use in tiny, critically ill newborns.

The specially modified pediatric-sized implantable pulse generator, called the Pediatric IPG, includes a Medtronic Micra sub-assembly that connects to an epicardial lead. While this makes the leadless pacemaker into one that uses leads, the resulting IPG is significantly smaller than any commercially available pacemaker previously on the market in the U.S.

The five infants in this case profile each received the modified Pediatric IPG at four separate institutions, and each surgery to implant the device was performed by a different cardiac surgeon. Two of the five cases were cared for at Children’s National. Cardiac surgeons Can Yerebakan, M.D., Ph.D., and Manan Desai, M.D. each performed one procedure.

The Pediatric IPG was authorized for use by emergency use exemptions from the federal Food and Drug Administration and with review and approval by each hospital’s Institutional Review Board, based on successful laboratory and pre-clinical models with favorable, though limited, results.

The patient benefit

All five infants were diagnosed with congenital complete heart block and required urgent pacing immediately after birth. The authors write:

“Permanent pacing in adults and older children is a routine, relatively simple implantation procedure. In the smallest of children, however, the generator is typically placed in the abdomen and can still present challenges in tiny babies under 2.5kg due to its bulk and dimensions, with risks of wound dehiscence, generator erosion and other complications.”

The authors note that the smaller profile of the Pediatric IPG reduces and has the potential to eliminate some of these challenges.

What’s next: Better delivery

Innovating smaller devices, including adapting current technology like the Medtronic Micra for pediatric use, is a good start but won’t be enough to eliminate some of the challenges for these patients. When a newborn or young child needs any pacemaker or defibrillator, they face open chest surgery. Their arteries and veins are just too small for even the smallest size transvenous pacemaker catheter.

That’s why Dr. Berul and engineers in the Sheikh Zayed Institute for Pediatric Surgical Innovation are working on a first-of-its-kind minimally invasive pericardial access tool. The team hypothesizes that this tool will allow for pacing and defibrillation therapy to be delivered through a single small port inserted through the skin that is about the size of a drinking straw.

You can read the full article Creative Concepts: Tiny Pacemakers for Tiny Babies in the journal Heart Rhythm.

infographic explaining tiny pacemaker

blood flow in the heart

High-risk newborns with hypoplastic left heart syndrome benefit from hybrid approaches

“Hybrid treatment enables even patients who are extremely high risk for surgery to have a survival advantage.” — Dr. Yerebakan.

Can Yerebakan, M.D., Ph.D., associate chief of Cardiac Surgery, and Joshua Kanter, M.D., director of Interventional Cardiology, created a multi-disciplinary team at Children’s National Hospital to perform the staged surgical approach known as the “hybrid strategy” to support the smallest, most fragile babies born with hypoplastic left heart syndrome (HLHS).

Today, the team performs more of these procedures than almost any other heart center in the United States, and they’ve successful completed it for neonates as small as 1 kg.

The approach gives high-risk babies time to recover from birth trauma and continue developing crucial organs before undergoing more traditional, more-invasive HLHS procedures that require open-heart surgery with cardiopulmonary bypass. Surgeons also have more time to make complete individualized risk assessments for next steps on each case, replacing the historical “one size fits all” operative pathway for HLHS.

Read more about the hybrid surgical strategy for HLHS.

doctors doing heart surgery

Innovative hypoplastic left heart syndrome treatment offers hope for highest risk children

doctors doing heart surgery

A recently published study in the Journal of Thoracic and Cardiovascular Surgery is a unique report of outcomes for infants treated using a staged surgical approach such as the “hybrid strategy.”

Adopting a staged surgical strategy as the standard of care for medically fragile children with hypoplastic left heart syndrome (HLHS), a critical congenital heart defect, shows promise as an alternative care path for those who may not be ideal candidates for open heart surgery immediately after birth.

A recently published study in the Journal of Thoracic and Cardiovascular Surgery is a unique report of outcomes for infants treated using a staged surgical approach such as the “hybrid strategy.” This initially less-invasive technique involves the placement of small bands on both lung vessels, with or without the placement of a stent on the ductus arteriosus, as the first stage in surgical palliation.

The study reports results from applying this hybrid approach as a bridge to either a delayed Norwood operation or a comprehensive stage II operation. Over 3.5 years, 30 patients with HLHS were considered very high risk for surgery based on their preoperative risk factors such as low birth weight and/or gestational age, shock, and other medical conditions. During that time, the overall survival rate for this group was 70 percent. In the past, using traditional approaches, the survival chance for infants with HLHS and these high-risk factors was extremely limited.

Why it matters

This new surgical strategy gives the baby extra time to grow and allows doctors to collect detailed analysis of potentially treatable accompanying conditions. Furthermore, high-risk babies recover from birth trauma and have the chance to continue developing crucial organs before undergoing more traditional procedures for HLHS that require open-heart surgery with cardiopulmonary bypass. It also allows surgeons to make an individualized risk assessment for which surgical step should be taken next, replacing the historical “one size fits all” operative pathway for HLHS. The traditional operative pathway for HLHS is a series of three open-heart surgical procedures: the traditional Norwood operation, the bidirectional Glenn and the Fontan.

Advancing the standard of care for HLHS patients beyond the current best practice approach to improve outcomes for more newborns has been slow for several reasons, the authors note. One main reason is that performing a hybrid procedure on these particularly fragile infants requires advanced devices and additional technical expertise. As one example, the authors note that until recently, there was no stent available in the appropriate sizes and with the right material properties to work within such a tiny ductus arteriosus. However, case-by-case expanded access approval by the FDA has brought a new stent designed specifically for this use from Europe to the U.S. for the first time.

What they’re saying

“The Norwood operation revolutionized the care of children with HLHS in the 1980s and gave them a chance for survival,” says Can Yerebakan, M.D., senior author of the study and cardiac surgeon at Children’s National who oversees the hybrid program alongside Joshua Kanter, M.D., director of Interventional Cardiology. “This staged decision-making strategy may give the same kind of hope and offers an alternative pathway of care for high-risk patients who would otherwise have a dismal prognosis and extremely low chance   of survival in the newborn period. The success in these cases is, however, based on a multidisciplinary team approach.”

What’s next?

“This strategy not only shows promise for improved short-term survival in high-risk patients, but also boasts the potential to convert some patients to two-chamber circulation instead of one, which our team has done with 100% survival,” says Nicolle Ceneri, M.D., first author of the study and pediatric resident at Children’s National. “As time goes on, we are eager to discover how the use of this approach during such a tenuous period impacts the long-term outcomes for these children and their quality of life.”

Read about the smallest baby born with HLHS to survive to 18 months, who was treated using this hybrid surgical approach at Children’s National Hospital.

Ashley Vela Mercedes

Staged surgical hybrid strategy changes outcome for baby born at 28 weeks with HLHS

Ashley Vela MercedesA staged, hybrid cardiac surgical strategy can give fragile infants with hypoplastic left heart syndrome (HLHS) critical time to grow and get stronger. It also gives doctors more time to understand and care for any complicating conditions before necessary open-heart surgery. Doctors at Children’s National Hospital used such a staged approach, called the “hybrid strategy,” to care for Ashley Vela Mercedes, who was born at only 28-weeks-old weighing 1.1 kilos.

Ashley, who is now a smiling and happy 18-month-old, is believed to be the smallest infant born at 28-weeks with HLHS to survive to this age. Though she will need ongoing care and future procedures, her family is grateful for the knowledge and technical expertise of her care team at Children’s National.

The hybrid program at Children’s National is led by Can Yerebakan, M.D., cardiac surgeon, and Joshua Kanter, M.D., director of Interventional Cardiology.

A hypoplastic left heart syndrome miracle

Ashley Vela Mercedes is a happy, smiling 18-month-old. She’s also a true miracle — the smallest baby in the world with HLHS to survive to this age.

Born when her mom was only 28 weeks pregnant, she was 1.1 kilos/2.4 pounds when she arrived — the size of a beanie baby stuffed animal — and her heart was about the size of a grape.

Between her premature birth and her medical issues including her critical HLHS heart condition, her parents, Ana Mercedes and Axel Vela were told that Ashley was unlikely to survive.

The Velas were frustrated, sad and scared. It started to sound like there wasn’t much hope for their tiny baby. They had always dreamed of having a family of their own. Nothing had prepared them for this.

Hope in the hybrid procedure

Their cardiologist, Jennifer Lindsey, M.D., wasn’t ready to give up either. She reached out to the team at Children’s National Hospital to see if Ashley might be considered for a new type of surgery — called a “hybrid procedure.” She hoped that this hybrid procedure might stabilize Ashley’s heart until she could grow strong enough for the open-heart surgeries she would need later.

Hybrid heart procedures blend traditional surgery and a minimally invasive interventional, or catheter-based, procedure. A stent is implanted in the newborn’s ductus arteriosus to hold it open and keep the baby’s blood flowing more efficiently. Usually, the ductus serves as a normal fetal blood vessel that increases blood flow to the mother’s placenta while in utero and closes after the baby is born, when it is not needed.

The hybrid procedure to hold open the ductus isn’t a permanent fix — it just buys the baby extra time to grow and develop before open-heart surgery to start rebuilding the heart in a more sustainable way. They are only considered an option for infants at extremely high risk for open-heart surgery. That’s also why very few congenital heart centers in the world offer them.

The hybrid team at Children’s National is led by Drs. Yerebakan and Kanter have worked together on more hybrid procedures for tiny and fragile infants than most other places. They’ve also worked with the U.S. Food and Drug Administration to safely bring a smaller and more flexible, toothpick-sized stent to the U.S. from Europe that’s made especially for use in the ductus arteriosus of special cases like Ashley.

Record-setting smallest hybrid surgery

Ashley Vela MercedesAccording to Gil Wernovsky, M.D., a cardiac intensive care doctor at Children’s National and Ashley’s Children’s National cardiologist, her birth weight was too low — she weighed 1.1 kilos or 2.4 pounds — for surgery. Her lungs also were not developed enough. She was so small, she lived in the hospital for several more weeks under the care of Dr. Lindsey. Dr. Wernovsky credits the team at Inova Children’s Hospital for providing the support Ashley needed so she could grow and develop to a place where the hybrid procedure was possible.

When she reached 1.7 kilos or 3.7 pounds, she was transported to the Cardiac Intensive Care Unit at Children’s National Hospital for her first procedure, the hybrid. At the time, she was officially the smallest baby to have a hybrid procedure at Children’s National. After the surgery, the Children’s National CICU was Ashley’s home for almost her entire first year of life.

“Landing here at Children’s was a blessing because we thought she was going to die. What has happened here is a miracle,” said Ana Mercedes. “I would like to tell Dr. Yerebakan and Dr. d’Udekem (the chief of Cardiac Surgery at Children’s National) that what they have done with my daughter is incredible, and I will never be able to fully repay them for their efforts.”

Over the next 11 months in the hospital, Ashley had many surgeries and catheterizations, countless other medical procedures and tests, and many, many ups and downs, including some very scary times when she required extracorporeal membrane oxygenation (ECMO) for critical life support.

Celebrating and thriving at home

Ashley Vela MercedesIn July 2021, Ashley went home for the first time in her life. She hasn’t needed to be hospitalized since her discharge. She’s monitored jointly by Dr. Lindsey and the Children’s National single ventricle monitoring program. That program stays in touch with families virtually three times each week. Her care team keeps up with her growth and development through telehealth. Ana Mercedes shares videos and photos of Ashley as part of her routine updates to the clinical team.

She still needs some medical support at home and will likely need additional medical interventions down the road, but for the time being, she is a more independent, happier and thriving little girl.

And she’s a miracle — she is the smallest baby in the world born with HLHS at such a small size and weight to survive to this age.

Ana Mercedes dreams of taking Ashley to the Dominican Republic one day, so they can enjoy the famous beaches and Ashley can be introduced to her heritage since that’s where Ana Mercedes is from.

“We are overall doing well. We have received support from our family and employers,” said Ana Mercedes. “We are extremely grateful to everyone who has given us a hand during this challenging time.”

The last year has been a roller coaster, but Ashley has made incredible progress and exceeded everyone’s expectations. Dr. Wernovsky notes, “Last year at Christmas time, this little girl was on her fourth catheter procedure and had been in intensive care for her entire life. One year later, she’s at home with her family and celebrating — that’s quite the Christmas miracle.”

International cardiac surgery experts join Children’s National

Children’s National Health System is pleased to announce the addition of Can Yerebakan, M.D., and Karthik Ramakrishnan, M.D., to our team of pediatric cardiac surgeons.

Can YerebakanDr. Yerebakan comes to Children’s National from the prestigious Pediatric Heart Center in Giessen, Germany, where he was appointed as an Associate Professor of Cardiac Surgery at the Justus-Liebig-University and performed hybrid treatment of hypoplastic left heart syndrome (HLHS).  He was deeply involved in mechanical circulatory support and pediatric heart transplantation in Giessen – a leading center for pediatric heart transplantation in Europe. He also served as Chief of Clinical and Experimental Research in the Department of Congenital Cardiac Surgery at Justus-Liebig-University of Giessen, where he acquired several research grants and contributed to more than 20 abstract presentations at national and international meetings and 20 papers in peer-reviewed journals. . Dr. Yerebakan has published approximately 70 scientific papers with more than 160 impact points in three different languages. He is an active reviewer for journals such as the Journal of Thoracic and Cardiovascular Surgery, European Journal of Cardiothoracic Surgery and serves as assistant editor of the Interactive Cardiovascular and Thoracic Surgery journal and Multimedia Manual Cardiothoracic Surgery journal, both of which are official journals of the European Association of Cardiothoracic Surgery. He has had a distinguished academic career and is internationally recognized for his contributions to the field of congenital cardiac surgery, particularly in the treatment of HLHS and novel surgical treatments for heart failure in the pediatric population. Prior to his tenure at Pediatric Heart Center, Dr. Yerebakan completed his fellowship at Children’s in 2011.

Karthik RamakrishnanDr. Ramakrishnan joined Children’s National as a fellow in 2014 after completing his fellowship in congenital cardiac surgery at two major centers in Australia. After his two-year fellowship at Children’s, he joined the faculty. Dr. Ramakrishnan has extensive experience in managing children with congenital heart disease. Apart from routine open heart procedures, he has a special expertise in extracorporeal membrane oxygenation (ECMO) procedures and patent ductus arteriosus (PDA) ligation in extremely premature babies. He also has a keen interest in studying clinical outcomes after pediatric heart surgery. His research projects have included analysis of the United Network of Organ Sharing (UNOS) and the Pediatric Health Information System® (PHIS) databases, and his research has resulted in numerous presentations at national and international meetings. Dr. Ramakrishnan is currently the principal investigator at Children’s National for the Pediatric Heart Transplant Study (PHTS) group and the study coordinator for the Congenital Heart Surgeons’ Society (CHSS) studies. He also is a member of the PHTS working group on the surveillance and diagnosis of cellular rejection, and his clinical studies have resulted in several publications in top peer-reviewed journals.

Drs. Yerebakan and Ramakrishanan join Richard Jonas, M.D., Co-director of Children’s National Heart Institute and Chief of Cardiac Surgery, and Pranava Sinha, M.D., on the Cardiac Surgery attending staff.  We look forward to continuing to strengthen our program with the addition of these physicians.