Prenatal features of ductus arteriosus-related branch pulmonary stenosis in fetal pulmonary atresia

2025 American Association for Thoracic Surgery Congenital Cardiac Surgery Working Group- Expert consensus document on the management of patients with pulmonary atresia with intact ventricular septum

BACKGROUND

Pulmonary atresia with intact ventricular septum (PAIVS) presents significant morphologic and pathophysiologic variation. Outcomes depend on individual patient characteristics and the determination of appropriate triage for neonatal catheter-based and surgical therapy. Therapeutic interventions and practice patterns vary significantly. There is currently no consensus on many diagnostic and therapeutic options in clinical care, and sizeable gaps in evidence exist.

METHODS

The American Association for Thoracic Surgery Congenital Clinical Practice Standards Committee identified PAIVS as a complex lesion for which practitioners could benefit from an expert consensus document to provide management guidelines. This document focuses on the diagnosis, triage, identification and timing of optimal surgical or interventional strategies, and postinterventional care of patients with PAIVS.

RESULTS/CONCLUSIONS

In this document, we identify gaps in knowledge in the care for PAIVS and provide evidence-based and expert-derived consensus statements with available strength of class of recommendation and level of evidence with supporting data and discussion. Section 1 addresses the current state of fetal diagnosis and management and the potential indications for fetal interventions. Section 2 discusses postnatal diagnosis and anatomic characterization, including right ventricle, tricuspid valve, and coronary circulation, as well as the appropriate triage of patients for initial management strategies. Section 3 concentrates on the relative efficacy of procedures to establish pulmonary blood flow and decompress the right ventricle when indicated. We also examine the appropriate use of mechanical circulatory support and indications for heart transplantation in patients with the most severe form of PAIVS. Finally, Section 4 focuses on long-term outcomes, especially with single-ventricle palliation and ongoing risk related to possible ischemia in patients with right ventricle-dependent coronary circulation. Much remains to be learned concerning the care of children and adults with PAIVS. Future research and careful review of outcomes will continue to guide clinical decision-making.

Role of Cardiac CTA to Evaluate Branch Pulmonary Artery Stenosis and Ductal Insertion Pattern in Right-Sided Congenital Heart Defects

There is limited experience in evaluating abnormal ductus arteriosus (DA) insertion pattern by contrast-enhanced cardiac computed tomography (cardiac CT) in patients with right-sided obstructive cardiac defects. Retrospective review of 38 infants with right-sided obstructive cardiac defects who underwent a preoperative cardiac CT between 2016 and 2021. We reviewed the types of cardiac lesions, patterns of ductal insertion, frequency of pulmonary artery (PA) stenosis requiring intervention, total dose length product (DLP), and effective radiation dose. Of 38 infants, 45% were female, the median gestational age and weight were 37 (range 34-40) weeks and 2.95 (range 2-4) kg. The most common pathologies were pulmonary atresia with ventricular septal defect (24%) and tetralogy of Fallot (24%). The abnormal ductal insertion patterns were DA inserting into the left PA in 39%, DA bifurcating into branch PA in 32%, and DA inserting into the right PA in 13%. Of the 38 infants, 76% developed branch PA stenosis requiring intervention. Among patients with abnormal DA insertion, 44% required branch PA arterioplasty during their index surgery compared to 17% without abnormal DA insertion. Regardless of the type of abnormal DA insertion, 67% developed bilateral branch PA stenosis over time. The mean DLP was 8 mGy-cm and the mean calculated effective radiation dose was 0.312 mSv. The utilization of contrast-enhanced cardiac CT in infants with right-sided obstructive heart defects can offer crucial insights into abnormal ductus arteriosus insertion patterns. This information is valuable for effective procedure planning and for monitoring the development of branch pulmonary artery stenosis.

Association of right aortic arch and agenesis of ductus arteriosus in prenatal tetralogy of Fallot spectrum and its clinical implications

OBJECTIVE

In our center, we observed an increased frequency of right aortic arch (RAA) with an agenesis of the ductus arteriosus (ADA) in prenatally diagnosed tetralogy of Fallot (ToF) and its variations. This study aimed to determine whether there is an association of RAA and ADA in fetuses with ToF. Distribution of genetic anomalies and impact on postnatal outcome were further evaluated.

METHOD

Single-center retrospective observational study including pregnancies with prenatal diagnosis of ToF from 2010 to 2023. All cases were subdivided into ToF with pulmonary stenosis (PS) and pulmonary atresia (PA). Clinical and echocardiographic databases were reviewed for pregnancy outcome, genetic anomalies, and postnatal course.

RESULTS

The cohort included 169 cases, 124 (73.4%) with ToF/PS and 45(26.6%) with ToF/PA. Agenesis of the ductus arteriosus was significantly associated with RAA in both subtypes of ToF (p = 0.001) compared to left aortic arch and found in 82.5% (33/40) versus 10.7% (9/84) of fetuses with ToF/PS and in 57.1% (8/14) versus 12.9% (4/31) of fetuses with ToF/PA. In both ToF/PS and ToF/PA, RAA/ADA versus RAA/patent DA revealed a significantly higher risk for the presence of genetic abnormalities, especially microdeletion 22q11.2, major aorto-pulmonary collateral arteries and a shorter time to complete surgical repair.

CONCLUSION

We demonstrated a significantly increased frequency of RAA/ADA in patients with prenatally diagnosed ToF. Although this association revealed no significant impact on overall survival, the prenatal detection of RAA/ADA has implications for counseling, genetic evaluation and postnatal management.

Echocardiographic Predictors of Ductal Tissue-Related Branch Pulmonary Artery Stenosis in Pulmonary Atresia

Branch pulmonary artery (PA) stenosis due to ductus arteriosus (DA) tissue (DA-PS) contributes to the morbidity associated with pulmonary atresia (PAtr). We sought to identify preoperative echocardiographic features predictive of DA-PS. Patients consecutively encountered with PAtr and a DA-dependent pulmonary circulation at birth who underwent intervention in our program over a 5-year period were identified and records reviewed. Preoperative echocardiograms were reviewed to identify features that predicted postoperative DA-PS. Seventy patients with PAtr met inclusion criteria and 36 (51%) had DA-PS. At preoperative echocardiography, the proximal diameter of the PA ipsilateral to the DA was smaller in those with versus without DA-PS (Z-score - 4.8 ± 1.7 vs - 1.1 ± 1.7, respectively p < 0.001). PA origins could not be imaged on the same axial plane in 21/36 (58%) with versus 2/34 (6%) without DA-PS. Patients with DA-PS had an obtuse posterior angle of the PA bifurcation compared to those without (128 ± 17° and 87 ± 21°, p < 0.001), and a posterior angle of > 100° best predicted DA-PS with a sensitivity of 97% and specificity of 76%. An abnormal PA relationship and/or an obtuse posterior bifurcation angle had a sensitivity, specificity, positive and negative predictive value for DA-PS of 78%, 94%, 90% and 86%, respectively. Finally, DA insertion was into the ipsilateral PA in 26/36 (72%) of cases with DA-PS. A smaller proximal ipsilateral PA diameter, inability to image the PAs in the same plane, a posterior PA bifurcation angle of > 100°, and insertion of the DA in the ipsilateral PA demonstrated by echo are useful in identifying patients at risk for DA-PS.