Pulmonary Artery Growth After Palliation of Congenital Heart Disease With Duct-Dependent Pulmonary Circulation

Ductal stenting vs. surgical shunting in late presenting duct-dependent pulmonary circulation: a single-center experience

Introduction

PDA stenting is an option to mBTT shunt for younger patients; nevertheless, few reports of this palliative approach have been made for the late presenter population, especially for patients who are older than 30 days but under 5 years. This study aimed to evaluate the clinical result and intra-hospital costs of ductal stenting in late-presenting patients in comparison to surgical shunting.

Methods

A single-center, retrospective cohort study was conducted from August 2016 to August 2022. This study included patients with pulmonary duct dependent CHD who were hospitalized for palliative therapy. The extracted data were baseline characteristics, clinical findings, supportive examination findings, complications, outcomes, and length of stay of the patients. Monitoring was carried out during treatment up to 30 days after the procedure.

Results

A total of 143 patients were included in the analysis; 43 patients underwent PDA stent and 100 patients underwent mBTT shunt with median age of PDA stent group 110 (31-1,498) days and mBTT shunt group 174.5 (30-1,651) days. Primary outcome composite was not significant in both groups including 30 days mortality [6 (14%) vs. 14 (14%), p = 1.000], reintervention [1 (2.3%) vs. 7 (7%), p = 0.436], and 30 days rehospitalization [0 (0%) vs. 2 (2%), p = 0.319]. Secondary outcome analysis showed shorter ICU length of stay in the PDA stent group [2 (0-16) days vs. 4 (1-63) days, p = 0.002].

Conclusions

PDA stent has an outcome that is non inferior from the mBTT shunt procedure in the composite outcome including 30 days mortality, reintervention, and 30 days rehospitalization but significantly lower in ICU length of stay.

Early and Long-Term Clinical Outcomes of Ductal Stenting Versus Surgical Aortopulmonary Shunt Among Young Infants with Duct-Dependent Pulmonary Circulation

Surgical aortopulmonary shunting (SAPS) and ductal stenting (DS) are the main palliations in infants with cyanotic congenital heart diseases (CHD). We aimed to study the safety and efficacy of DS and to compare it with SAPS as a palliative procedure in infants with CHD and duct-dependent pulmonary circulation. Retrospective institutional clinical data review of consecutive infants aged < 3 months who underwent DS or SAPS over 5 years. The primary outcome was procedural success which was defined as event-free survival (mortality, need for re-intervention, procedural failure) at 30 days post-procedure. The secondary outcome was defined by a composite of death, major adverse cardiovascular events, or need for re-intervention at 6 months and on long-term follow-up. We included 102 infants (DS, n = 53 and SAPS, n = 49). The median age at DS and SAPS was 4 days (IQR 2.0-8.5) and 8 days (IQR 4.0-39.0), respectively. The median weight at intervention was 3.0 kg (IQR 3.0-3.0) and 3.0 kg (IQR 2.5-3.0) in the two respective arms. Tetralogy of Fallot with pulmonary atresia was the most common indication for DS and SAPS. The 30-day mortality was significantly higher in SAPS group as compared with DS group (p < 0.05). However, 30-day major adverse cardiac events (MACE) rates were similar in both groups (p = 0.29). DS was associated with shorter duration of mechanical ventilation, duration of stay in the intensive care and hospital stay than with SAPS. At 6 months, there was no significant difference in terms of mortality or event-free survival. Long-term MACE-free survival was also comparable (p = 0.13). DS is an effective and safer alternative to SAPS in infants with duct-dependent pulmonary circulation, offering reduced procedure-related mortality and morbidity than SAPS. Careful study of ductal anatomy is crucial to procedural success. However, long-term outcomes are similar in both procedures.

Comparison of ductus stent versus surgical systemic-to-pulmonary shunt as initial palliation in patients with univentricular heart

OBJECTIVES

In this study, we aimed to compare infants with univentricular hearts who underwent an initial ductus stenting to those receiving a surgical systemic-to-pulmonary shunt (SPS).

METHODS

All infants with univentricular heart and ductal-dependent pulmonary blood flow who underwent initial palliation with either a ductus stenting or a surgical SPS between 2009 and 2022 were reviewed. Outcomes were compared after ductus stenting or SPS including survival, probability of re-interventions and the probability to reach stage II palliations.

RESULTS

A total of 130 patients were evaluated, including 49 ductus stenting and 81 SPSs. The most frequent primary diagnosis was tricuspid atresia in 27, followed by pulmonary atresia with intact ventricular septum in 19 patients. There was comparable hospital mortality (2.0% stent vs 3.7% surgery, P = 0.91) between the groups, but shorter intensive care unit stay (median 1 vs 7 days, P < 0.01) and shorter hospital stay (median 7 vs 17 days, P < 0.01) were observed in patients with initial ductus stenting, compared to those with SPS. However, acute procedure-related complications were more frequently observed in patients with ductus stenting, compared with those with SPS (20.4 vs 6.2%, P = 0.01), and 10 patients needed a shunt procedure after the initial ductus stent. The cumulative incidence of reaching stage II was similar between ductus stenting and SPS (88.0 vs 90.6% at 12 months, P = 0.735). Pulmonary artery (PA) index (median 194 vs 219 mm2/m2, P = 0.93) at stage II was similar between patients with ductus stenting and SPS. However, the ratio of the left to the right PA index [0.69 (0.45-0.95) vs 0.86 (0.51-0.84), P = 0.015] was higher in patients who reached stage II with surgical shunt physiology, compared with patients with ductus stent physiology.

CONCLUSIONS

After initial ductus stenting in infants with univentricular heart, survival is comparable and post-procedural recovery shorter, but more acute stent dysfunctions and lower development of left PA are observed, compared to acute shunt dysfunctions. The less invasive procedure and shorter hospital stay are at the expense of more stent reinterventions.

Optimal Surgical Management of Tetralogy of Fallot

Tetralogy of Fallot with pulmonary stenosis has a diverse clinical spectrum with the degree of right ventricular outflow tract obstruction (RVOTO) and size of the branch pulmonary arteries driving clinical management. Optimal surgical management involves consideration of patient clinical status and degree and location (subvalvar, valvar, and supravalvar) of RVOTO. Timing of repair requires multidisciplinary decision-making and complete surgical repair with relief of RVOTO by either transannular patch or valve sparing repair techniques. The central goals of contemporary surgical management of tetralogy of Fallot incorporate maximizing survival, minimizing reintervention, and preserving right ventricular function across the lifespan.

Considerations in Timing of Surgical Repair in Tetralogy of Fallot

Certain aspects of the treatment of tetralogy of Fallot (TOF) repair remain controversial. The optimal timing of the elective repair of asymptomatic patients and the ideal strategy for managing symptomatic neonates and infants with TOF are still debated despite years of experience in TOF treatment. In this article, we discuss why a surgical correction at 3-6 months of age is likely the ideal time frame for the elective repair of TOF. We also elaborate on our strategy for managing symptomatic neonates and infants with TOF and why we prefer an early single-stage primary repair.

Blalock-Taussig Shunt versus Ductal Stenting as Palliation for Duct-Dependent Pulmonary Circulation

Objectives

There is limited data published from outside North America and Europe comparing the outcomes of a modified Blalock-Taussig shunt (MBTS) and ductal stenting as the first palliative procedure for infants with duct-dependent pulmonary circulation. This study reports the National Heart Center's, in Muscat, Oman, experience in comparing the outcomes of these 2 interventions.

Methods

This retrospective study included all infants with duct-dependent pulmonary circulation who received either a MBTS or ductal stenting from 2016-2019. The primary outcomes were death or re-interventions. Secondary outcomes included death, subsequent re-interventions, survival to subsequent surgical intervention, survival to hospital discharge, post-procedural mechanical ventilation and duration of intensive care unit stay.

Results

A total of 71 patients were included in the study, 33 (46%) of whom received ductal stenting. The prevalence of the primary outcome (death or re-intervention) in the patent ductus arteriosus (PDA) stent group was 54.5% versus 31.6% in the MBTS group but this was not statistically significant (P = 0.06). There was no difference between the 2 groups in terms of time to next surgical intervention (P = 0.233). The PDA stent group had shorter post-procedural, mechanical ventilation and intensive care unit stay durations (P <0.05). Syndromic patients were at higher risk of mortality compared to non-syndromic patients.

Conclusion

MBTS and ductal stenting are both acceptable modalities as a palliative intervention for infants with duct-dependant pulmonary circulation. Syndromic patients are at higher risk of mortality. This can be considered an important factor for patient selection.

Stenting of high-tortuous ducts in duct-dependent pulmonary circulation: essential points to consider before deciding on stenting

Despite the advancements in the technique of duct stenting (DS) in patients with duct-dependent pulmonary circulation (DDPC) and the valuable role of DS in preventing the risk of surgical creation of shunts and early repair, not all ducts are amenable to being stented, and not all interventions with DS are safe and can achieve positive outcomes. Very few studies focusing on tortuous ducts have been conducted until now. Their results showed that stenting of highly tortuous ducts has the same risk as surgical options. This type of stenting has greater possibility of complications, early in-stent thrombosis, and stent failure than do other duct types. In such cases, the surgical options could be superior to DS and have better outcomes. This report aims to review the very scarce available data about stenting of high-tortuous ducts and criticisms of performing DS in ducts associated with pulmonary stenosis and to highlight the essential points that must be considered before deciding on intervention.

Stent Strut Dilation in Branch Pulmonary Artery Stenosis Following Stenting of Arterial Duct in Duct-dependent Pulmonary Circulation

To assess the feasibility and outcome of stent strut dilation after arterial duct stenting with associated branch pulmonary artery (BPA) stenosis. Stenting of arterial duct in infants with duct-dependent pulmonary circulation is technically challenging. The presence of BPA stenosis is a relative contraindication for stent implantation. Infants with duct-dependent pulmonary circulation and associated BPA stenosis were assessed either by transthoracic echocardiogram alone or additional computerized tomography angiogram when required. Following ductal stenting, the stent struts of the stenosed BPA were crossed with an additional 0.014″ coronary guide wire and dilated using coronary balloons (2.0 or 2.5 mm in diameter). Seventeen (12 male) patients were considered for the procedure. The median age and weight were 27 days (range 2-94) and 2.6 kg (range 2.2-5), respectively. Fourteen patients (82.4%) underwent stent strut dilation after arterial duct stenting. Struts to left pulmonary artery was opened in 9 (64.3%) and right pulmonary artery in 5 (35.7%). The mean systemic oxygen saturation increased from 66.23 ± 8.9% at baseline to 86 ± 2.2% immediately after the stent deployment and final saturations after stent strut dilation were 89.29 ± 4.3%. Angiographic pulmonary flow improved in all cases. Stent strut dilation could not be done in 3 patients due to unfavorable anatomy. One patient had acute stent thrombosis and died in the hospital. Two others died during follow-up, during an acute febrile illness and gastroenteritis. All survivors underwent cardiac surgery and were on regular follow-up. Strut dilation of BPA stenosis is feasible to augment pulmonary blood flow, following arterial duct stenting. This procedure may be useful in selected patients with BPA stenosis to have uniform growth of pulmonary arteries.

The American Association for Thoracic Surgery (AATS) 2022 Expert Consensus Document: Management of infants and neonates with tetralogy of Fallot

OBJECTIVE

Despite decades of experience, aspects of the management of tetralogy of Fallot with pulmonary stenosis (TOF) remain controversial. Practitioners must consider newer, evolving treatment strategies with limited data to guide decision making. Therefore, the TOF Clinical Practice Standards Committee was commissioned by the American Association for Thoracic Surgery to provide a framework on this topic, focused on timing and types of interventions, management of high-risk patients, technical considerations during interventions, and best practices for assessment of outcomes of the interventions. In addition, the group was tasked with identifying pertinent research questions for future investigations. It is recognized that variability in institutional experience could influence the application of this framework to clinical practice.

METHODS

The TOF Clinical Practice Standards Committee is a multinational, multidisciplinary group of cardiologists and surgeons with expertise in TOF. With the assistance of a medical librarian, a citation search in PubMed, Embase, Scopus, and Web of Science was performed using key words related to TOF and its management; the search was restricted to the English language and the year 2000 or later. Articles pertaining to pulmonary atresia, absent pulmonary valve, atrioventricular septal defects, and adult patients with TOF were excluded, as well as nonprimary sources such as review articles. This yielded nearly 20,000 results, of which 163 were included. Greater consideration was given to more recent studies, larger studies, and those using comparison groups with randomization or propensity score matching. Expert consensus statements with class of recommendation and level of evidence were developed using a modified Delphi method, requiring 80% of the member votes with 75% agreement on each statement.

RESULTS

In asymptomatic infants, complete surgical correction between age 3 and 6 months is reasonable to reduce the length of stay, rate of adverse events, and need for a transannular patch. In the majority of symptomatic neonates, both palliation and primary complete surgical correction are useful treatment options. It is reasonable to consider those with low birth weight or prematurity, small or discontinuous pulmonary arteries, chromosomal anomalies, other congenital anomalies, or other comorbidities such as intracranial hemorrhage, sepsis, or other end-organ compromise as high-risk patients. In these high-risk patients, palliation may be preferred; and, in patients with amenable anatomy, catheter-based procedures may prove favorable over surgical palliation.

CONCLUSIONS

Ongoing research will provide further insight into the role of catheter-based interventions. For complete surgical correction, both transatrial and transventricular approaches are effective; however, the smallest possible ventriculotomy should be utilized. When possible, the pulmonary valve should be spared; and if unsalvageable, reconstruction can be considered. At the conclusion of the operation, adequate relief of the right ventricular outflow obstruction should be confirmed, and identification of a significant fixed anatomical obstruction should prompt further intervention. Given our current knowledge and the gaps identified, we propose several key questions to be answered by future research and potentially by a TOF registry: When to palliate or proceed with complete surgical correction, as well as the ideal type of palliation; the optimal surgical approach for complete repair for the best long-term preservation of right ventricular function; and the utility, efficacy, and durability of various pulmonary valve preservation and reconstruction techniques.

Short- and medium-term outcomes for patent ductus arteriosus stenting in neonates ≤2.5 kg with duct-dependent pulmonary circulation

BACKGROUND

Morbidity with surgical systemic-to-pulmonary artery shunting (SPS) in infants ≤2.5 kg has remained high. Patent ductus arteriosus (PDA) stenting may be a valid alternative. The objective of this study is to evaluate outcomes following PDA stenting in patients ≤2.5 kg from four large tertiary centers.

METHODS

Retrospective review of all neonates ≤2.5 kg with duct-dependent pulmonary circulation who underwent PDA stenting. Procedural details, pulmonary arterial growth, reinterventions, surgery type, and outcomes were assessed.

RESULTS

PDA stents were implanted in 37 of 38 patients attempted (18 female) at a median procedural weight of 2.2 kg (interquartile range [IQR], 2-2.4 kg). Seven patients (18%) had a genetic abnormality and 16 (42%) had associated comorbidities. The median intensive care unit stay was 4 days (IQR, 2-6.75 days), and the median hospital stay was 20 days (IQR, 16-57.25). One patient required a rescue shunt procedure, with three others requiring early SPS (<30 days postprocedure). Twenty patients (54%) required reintervention with either balloon angioplasty, restenting, or both. At 6-month follow-up, right pulmonary artery growth (median z-score -1.16 to 0.01, p = 0.05) was greater than the left pulmonary artery (median z-score -0.9 to -0.64, p = 0.35). Serious adverse effects (SAEs) were seen in 18% (N = 7) of our cohort. One patient developed an SAE during planned reintervention There were no intraprocedural deaths, with one early procedure-related mortality, and three interstage mortalities not directly related to PDA stenting.

CONCLUSIONS

PDA stenting in infants ≤2.5 kg is feasible and effective, promoting pulmonary artery growth. Reintervention rates are relatively high, though many are planned to allow for optimal growth before a definitive operation.

Patent Ductus Arteriosus Stent Versus Surgical Aortopulmonary Shunt for Initial Palliation of Cyanotic Congenital Heart Disease with Ductal-Dependent Pulmonary Blood Flow: A Systematic Review and Meta-Analysis

Background In patients with ductal-dependent pulmonary blood flow, initial palliation includes catheter-based patent ductus arteriosus (PDA) stent or surgical aortopulmonary shunt (APS). This meta-analysis aimed to compare outcomes between PDA stent and APS. Methods and Results A comprehensive literature search yielded six retrospective observational studies. Pooled adjusted hazard ratios (HR) were included to control for covariates and assess time to event analysis. Of 757 patients, 243 (32.1%) underwent PDA stent and 514 (67.9%) underwent APS. Pulmonary atresia with intact ventricular septum and expected biventricular repair were more common with PDA stent compared with APS (39.6% versus 21.2%, P<0.001 and 57.9% versus 46.6%, P=0.007, respectively). There was no statistically significant difference in mortality between PDA stent and APS (HR, 0.71; [95% CI, 0.26-1.93]; P=0.50). PDA stent was associated with lower risk of postprocedural complications (odds ratio [OR], 0.45; [95% CI, 0.25-0.81]; P=0.008), mechanical circulatory support (OR, 0.27; [95% CI, 0.09-0.79]; P=0.02), and shorter intensive care unit length of stay (-4.03 days; [95% CI, -5.99 to -2.07]; P<0.001), hospital length of stay (-5.54 days; [95% CI, -9.20 to -1.88]; P=0.003), and duration of mechanical ventilation (-3.41 days; [95% CI, -5.29 to -1.52]; P<0.001). There was no difference in pulmonary artery growth or hazard of unplanned reintereventions. Conclusions PDA stent has a similar hazard of mortality compared with APS. Benefits to PDA stent include shorter duration of mechanical ventilation, shorter hospital length of stay, and fewer complications. Differences in patient characteristics exist with more patients with pulmonary atresia with intact ventricular septum and expected biventricular repair undergoing PDA stent.

Patent ductus arteriosus stenting versus modified Blalock-Taussig shunt for palliation of duct-dependent pulmonary blood flow lesions

BACKGROUND

Patent ductus arteriosus (PDA) stenting is an alternative to modified Blalock-Taussig shunt (MBTS) as first-stage palliation of duct-dependent lesions. The superiority of one approach over the other is still controversial. Our objective was to compare PDA  stent versusMBTS for palliation in regard to safety, efficacy, and efficiency.

METHODS

From 2010 to 2021, 134 patients had first-stage palliation with either PDA stent (n = 83) or MBTS (n = 51). Twenty-seven patients failed the primary treatment and were converted to the other group. The study endpoints were hospital outcomes, interstage reintervention, and concomitant procedures at the second-stage palliation.

RESULTS

Patients with PDA stent were significantly younger. The prevalence of antegrade pulmonary blood flow (PBF) was higher in patients who had MBTS and graft thrombosis was higher in the PDA stent. Hospital stay was significantly longer in patients who had MBTS. Predictors of prolonged mechanical ventilation were low-weight, MBTS, and conversion. Intensive care unit stay significantly increased with conversion, low-weight, and antegrade PBF. The interstage intervention was required more frequently in PDA-stent group. Predictors of reintervention were conversion and pulmonary atresia with the intact interventricular septum. Pulmonary artery plasty was required more frequently during the second-stage palliation in PDA-stent group.

CONCLUSION

PDA stent is an alternative to MBTS for first-stage palliation. It is associated with shorter hospital stays and avoidance of surgery at the expense of a high rate of stent thrombosis and interstage reintervention. Conversion increased the risk of the procedure. More studies are needed to determine factors that affect PDA-stent outcomes and patient selection criteria.

Transcatheter Cardiac Interventions in the Newborn: JACC Focus Seminar

For neonates with critical congenital heart disease requiring intervention, transcatheter approaches for many conditions have been established over the past decades. These interventions may serve to stabilize or palliate to surgical next steps or effectively primarily treat the condition. Many transcatheter interventions have evidence-based records of effectiveness and safety, which have led to widespread acceptance as first-line therapies. Other techniques continue to innovatively push the envelope and challenge the optimal strategies for high-risk neonates with right ventricular outflow tract obstruction or ductal-dependent pulmonary blood flow. In this review, the most commonly performed neonatal transcatheter interventions will be described to illustrate the current state of the field and highlight areas of future opportunity.

Factors Influencing Reintervention Following Ductal Artery Stent Implantation for Ductal-Dependent Pulmonary Blood Flow: Results From the Congenital Cardiac Research Collaborative

BACKGROUND

Stenting of the patent ductus arteriosus (PDA) is an established palliative option for infants with ductal-dependent pulmonary blood flow. Following initial palliation, reintervention on the PDA stent is common, but risk factors have not been characterized.

METHODS

Infants with ductal-dependent pulmonary blood flow palliated with PDA stent between 2008 and 2015 were reviewed within the Congenital Cardiac Research Collaborative. Rates and risk factors for reintervention were analyzed.

RESULTS

Among 105 infants who underwent successful PDA stenting, 41 patients (39%) underwent a total of 53 reinterventions on the PDA stent, with all but one occurring within 6 months of the initial intervention. Stent redilation constituted the majority of reintervention (n=35; 66%) followed by additional stent placement (n=11; 21%) and surgical shunt placement (n=7; 13%). The majority of reintervention was nonurgent, and there were no deaths during the reintervention procedure. All but one reintervention occurred within 6 months of the initial procedure. On univariate analysis, risk factors for reintervention included anticipated single-ventricle physiology, lack of prior balloon pulmonary valvuloplasty, use of drug-eluting stent, and increased ductal tortuosity.

CONCLUSIONS

In infants with ductal-dependent pulmonary blood flow palliated with PDA stent implantation, reintervention is common, can be performed safely, and is associated with both anatomic/procedural factors and anticipated final physiology.

Outcome of ductus arteriosus stenting including vertical tubular and convoluted tortuous ducts with emphasis on technical considerations

Background

Ductal stenting is the preferred method of securing adequate pulmonary blood flow in patients with duct-dependent pulmonary circulation. The main limitation in most centers is the difficult vertical tubular or convoluted ducts that represent real challenges to interventional pediatric cardiologists. We present our experience in patent ductus arteriosus (PDA) stenting with some technical tips to overcome difficulties, especially in stenting tortuous or long tubular ducts. This study was conducted on all patients with cyanotic congenital heart disease who underwent PDA stenting between January 2011 and December 2018.

Results

We attempted to stent the PDA in 43 patients, with a success rate of 93% (40 patients) and only one procedural mortality. There was also one stent migration that needed to be treated with urgent surgery. Three-fourths of the patients had difficult ductal morphology and origin. One stent was used to cover the PDA in 27 patients (62.8%), two stents were used in 13 (30.2%), and three stents were used in 2 patients (4.6%). In-stent stenosis rate was 12.5% (5 patients) and the development of progressive left pulmonary artery stenosis was seen in two patients (5%). Pulmonary artery growth was adequate in all patients.

Conclusions

PDA stenting is an effective method of palliation for patients with duct-dependent pulmonary circulation. It has low morbidity and mortality rates. Stenting difficult ducts have become more feasible with evolving materials and techniques.

Supplementary Information

The online version contains supplementary material available at 10.1186/s43044-021-00210-4.

Blalock-Taussig Shunt versus Ductal Stent in the Palliation of Duct Dependent Pulmonary Circulation; A Systematic Review and Metanalysis

In infants with ductal dependent pulmonary blood flow, Blalock-Taussig (BT) shunt and Patent Ductus Arteriosus (PDA) stent, are two palliative procedures aimed to restore circulation. A systematic review and metanalysis was performed on studies comparing PDA stents and BT shunts, in accordance with PRISMA guidelines. Meta-analysis revealed the following; (1) a reduced risk of mortality [RR = 0.585 [0.399-0.859], (P = 0.006)], (2) a reduced risk of complications [RR = 0.523 [0.318-0.860], (P = 0.011), and (3) a reduced risk of ECMO use [R = 0.267 [0.101-0.706] (P = 0.008)], all in the stent group. Additionally, stent group showed higher post procedure oxygen saturation [SMD = 1.307 [95% CI 1.065-1.550], (P < 0.001)], and Nakata index [SMD = 0.679 95% CI [0.513 to 0.845], (P < 0.001)]. PDA stenting presents a viable alternative to BT shunt procedure with better post procedure stability.

Use of the ductal curvature index to assess the risk of ductal stenting in patients with duct-dependent pulmonary circulation

BACKGROUND

To evaluate whether a quantitative curvature threshold can contribute to risk stratification of ductal stenting in patients with a duct-dependent pulmonary circulation (DDPC).

METHODS

A single-center retrospective analysis was performed. The ductal curvature index (DCI) was calculated in 71 patients with DDPC. The ducts were divided into four classes based on quartile thresholds of DCI: class I (≤0.12), class II (0.13-0.33), class III (0.34-0.44), and class IV (≥0.45). The primary outcome of this study was defined as free from all of the following: (I) intervention related death, (II) need of unplanned surgery (III) need of unplanned pulmonary valve (PV) perforation with stent in right ventricular outflow tract (RVOT), and (IV) intervention related permanent complications.

RESULTS

Eighty percent of patients in class IV (DCI ≥0.45) failed to achieve the primary outcome; odds ratio (OR) 9 and 95% confidence interval (CI): 3.7-21.4 compared to 26.6% in all classes with DCI <0.45. 66.7% of these patients needed unplanned surgery or PVP with RVOT stent; OR 12.4 (95% CI: 4-39). 80% of major complications were observed in class IV (P<0.01). Need of pulmonary arterioplasty was in class IV 53.3%; OR 3.3 (95% CI: 1.5-7.1).

CONCLUSIONS

DCI can be useful to guide the clinical decision-making in patients with torqued ducts. Patients with a DCI ≥0.45 belong to a high-risk group, in which ductal stenting is associated with an elevated risk for early surgery or unplanned re-intervention.

Patent Ductus Arteriosus Stenting for All Ductal-Dependent Cyanotic Infants: Waning Use of Blalock-Taussig Shunts

[Figure: see text].

Arterial duct stent versus surgical shunt for patients with duct-dependent pulmonary circulation: a meta-analysis

BACKGROUND

Both systemic-pulmonary shunt and arterial duct stent could be the palliation of duct-dependent pulmonary circulation. We aimed to compare the safety and efficacy of the two approaches.

METHODS

The PubMed, EMBASE, and Cochrane Library databases were searched through December 2019 for studies comparing stent implantation and surgical shunt in duct-dependent pulmonary circulation. The baseline characteristics included ventricle physiology and cardiac anomaly. The main outcomes were hospital stay and total mortality. Additional outcomes included procedural complications, intensive care unit (ICU) stay, pulmonary artery growth at follow-up, and other indexes. A random- or fixed-effects model was used to summarize the estimates of the mean difference (MD)/risk ratio (RR) with 95% confidence intervals (CIs).

RESULTS

In total, 757 patients with duct-dependent pulmonary circulation from six studies were included. Pooled estimates of hospital stay (MD, - 4.83; 95% CI - 7.92 to - 1.74; p < 0.05), total mortality (RR 0.44; 95% CI 0.28-0.70; p < 0.05), complications (RR 0.49; 95% CI 0.30-0.81; p < 0.05) and ICU stay (MD, - 4.00; 95% CI - 5.96 to - 2.04; p < 0.05) favored the stent group. Significant differences were found in the proportions of patients with a single ventricle (RR 0.82; 95% CI 0.68-0.98; p < 0.05) or a double ventricle (RR 1.23; 95% CI 1.07-1.41; p < 0.05) between the stent and shunt groups. Additionally, pulmonary artery growth showed no significant differences between the two groups.

CONCLUSION

Arterial duct stent appears to have not inferior outcomes of procedural complications, mortality, hospital and ICU stay, and pulmonary artery growth in selected patients compared with a surgical shunt.

TRIAL REGISTRATION

CRD42019147672.

Evaluation of the Growth of Central Pulmonary Arteries Following Patent Ductus Arteriosus Stenting in Patients with Duct Dependent Pulmonary Circulation

Pulmonary arteries' (PAs) growth can be promoted by stenting of patent ductus arteriosus (PDA). This may result in better angle between the PDA and the PAs, allowing improved growth. In this study, we sought to evaluate the effect of PDA stenting on the growth of the pulmonary arteries by comparing their dimensions pre-stenting to their dimensions in the pre-second stage operations in patients with congenital heart diseases-duct-dependent pulmonary (CHD-DDP) circulation. Between January 2015 and December 2016, 58 neonates with CHD-DDP circulation underwent transcatheter PDA stenting and had evaluation of PAs growth before the second stage. Various parameters [Pre-branching right and left pulmonary artery (RPA, LPA) diameters, their Z scores, LPA/RPA ratio, McGoon's ratio and Nakata index] were recorded and compared pre-stenting and pre-second stage. The evaluation was done using catheterization or multislice computed tomography (MSCT). PDA stenting was successful in 49 patients out of 58 (84.5%) patients with an age of 13.5 ± 10.4 days and a weight of 2.9 ± 0.5 kg. Twenty-two (44.9%) patients had complex CHD-DDP, 14 (28.6%) patients had PA/IVS and 13 (26.5%) patients had PA/VSD. Pre-second stage RPA, LPA diameters and their Z scores increased significantly (RPA increased from 0.36 ± 0.05 cm to 0.60 ± 0.11 cm, P < 0.001, RPA Z-score increased from - 1.29 ± 0.91 to 0.81 ± 0.18, P < 0.001; LPA increased from 0.34 ± 0.06 cm to 0.58 ± 0.10 cm, P < 0.001, LPA Z-score increased from - 1.17 ± 0.86 to 0.97 ± 0.48, P < 0.001). McGoon's ratio increased significantly from 1.20 ± 0.11 to 1.61 ± 0.15 (P < 0.001). Nakata index increased from 105.94 ± 33.53 to 183.48 ± 40.58 mm²/m² (P < 0.001). However, LPA/RPA ratio did not change (0.96 ± 0.05 and 0.98 ± 0.16, P = 0.288). PDA stenting is effective in promoting the global and the individual pulmonary artery growth in congenital heart diseases with duct-dependent pulmonary circulation. In this study, we presented our experience with this approach in 2 tertiary care centers in the DELTA region of Egypt. PDA stenting, generally, showed symmetric growth of the pulmonary arteries with comparable results to the international figures.

Early and midterm results of ductal stent implantation in neonates with ductal-dependent pulmonary circulation: a single-centre experience

OBJECTIVE

We aimed to determine the early and midterm outcomes of ductal stenting in neonates with ductal-dependent pulmonary blood flow.

METHODS

Between January, 2014 and July, 2018, 102 patients who underwent 115 cardiac catheterisation procedures for ductal stent implantation in our department were retrospectively reviewed. The age of the neonates ranged from 3 to 30 days (median: 11 days) and their weights ranged from 1.8 to 5.8 kg (mean, 2.8 ± 0.53 kg). Fifty-two patients had functional single ventricle and 50 had biventricular physiology. Thirty-one patients' weights were <2,500 g (30.3%). The patent ductus arteriosus was vertical in 60 patients (58.8%). The mean ductal length was 12.4 ± 4.1 mm (range, 7.8-23 mm), and the mean narrowest ductal diameter was 2.1 ± 0.7 mm (range, 1.2-3.4 mm).

RESULTS

The technical success rate was 85.2%. Procedure-related mortality occurred in three patients (2.9%). After the procedure, the aortic oxygen saturation increased from a mean of 73.1 ± 6.2% to a mean of 90.4 ± 4.3% (p < 0.001), and the ductus diameter increased from a mean of 2.1 ± 0.7 mm to a mean of 4.2 ± 0.9 mm (p < 0.001). Either transcatheter or surgical reinterventions were required in 35 patients (34.3%) during the follow-up period after a median of 101 days (2-356 days). Thirty-three patients (32.3%) were bridged to surgical repair after a median of 288 days (163-650 days). The median duration of palliation with ductal stents was 210 days (range, 2-525 days).

CONCLUSION

Ductus arteriosus stenting may be a reasonable and effective alternative to surgery for the initial palliation procedure in neonates with ductus-dependent pulmonary flow.

Interventions on patent ductus arteriosus and its impact on congenital heart disease

The ductus arteriosus (DA) connects the pulmonary artery to the aorta to bypass the pulmonary circulation in utero. It normally closes within 24-72 hours after birth due to increased pulmonary resistance from an increase in oxygen partial pressure with the baby's first breath. Medical treatment can help close the DA in certain situations where closure is delayed. However, in duct-dependent cardiac defects, the presence of the DA is crucial for survival and as such medical and surgical techniques have evolved to prevent closure. This review aims to outline the two main management options for keeping a ductus arteriosus patent. This includes stenting the PDA and shunting via a modified Blalock-Taussig shunt. Whilst both techniques exist, multicentre trials have found equal mortality end points but significantly reduced morbidity with stenting than shunting. This is also reflected by shorter recovery times, reduced requirement for extracorporeal membrane oxygenation (ECMO), and improved quality of life, although stent longevity remains a limiting factor.

Impact of ductal stenting on pulmonary artery reconstruction in patients with duct-dependent congenital heart diseases-an institutional experience

OBJECTIVES

This study aims to review our institutional experience of ductal stenting (DS) on the growth of pulmonary arteries (PAs) and surgical outcomes of PA reconstruction in this subset of patients.

METHODS

This is a retrospective study done in neonates and infants up to 3 months of age with duct-dependent pulmonary circulation who underwent DS from January 2014 to December 2015. Post-stenting PA growth, surgical outcomes of PA reconstruction, post-surgical re-interventions, morbidity and mortality were analysed.

RESULTS

During the study period, 46 patients underwent successful DS, of whom 38 underwent presurgery catheterization and definite surgery. There was significant growth of PAs in these patients. Biventricular repair was done in 31 patients while 7 had univentricular palliation. Left PA augmentation was required in 13 patients, and 10 required central PA augmentation during surgery. The mean follow-up period post-surgery was 4.5 ± 1.5 years. No significant postoperative complications were seen. No early or follow-up post-surgery mortality was seen. Four patients required re-interventions in the form of left PA stenting based on the echocardiography or computed tomography evidence of significant stenosis.

CONCLUSIONS

DS provides good short-term palliation and the growth of PAs. However, a significant number of stented patients require reparative procedure on PAs at the time of surgical intervention. Acquired changes in the PAs following DS may be the reason for reintervention following PA reconstruction.

Resource Utilization in the First 2 Years Following Operative Correction for Tetralogy of Fallot: Study Using Data From the Optum's De-Identified Clinformatics Data Mart Insurance Claims Database

Background

Despite excellent operative survival, correction of tetralogy of Fallot frequently is accompanied by residual lesions that may affect health beyond the incident hospitalization. Measuring resource utilization, specifically cost and length of stay, provides an integrated measure of morbidity not appreciable in traditional outcomes.

Methods and Results

We conducted a retrospective cohort study, using de‐identified commercial insurance claims data, of 269 children who underwent operative correction of tetralogy of Fallot from January 2004 to September 2015 with ≥2 years of continuous follow‐up (1) to describe resource utilization for the incident hospitalization and subsequent 2 years, (2) to determine whether prolonged length of stay (>7 days) in the incident hospitalization was associated with increased subsequent resource utilization, and (3) to explore whether there was regional variation in resource utilization with both direct comparisons and multivariable models adjusting for known covariates. Subjects with prolonged incident hospitalization length of stay demonstrated greater resource utilization (total cost as well as counts of outpatient visits, hospitalizations, and catheterizations) after hospital discharge (P<0.0001 for each), though the number of subsequent operative and transcatheter interventions were not significantly different. Regional differences were observed in the cost of incident hospitalization as well as subsequent hospitalizations, outpatient visits, and the costs associated with each.

Conclusions

This study is the first to report short‐ and medium‐term resource utilization following tetralogy of Fallot operative correction. It also demonstrates that prolonged length of stay in the initial hospitalization is associated with increased subsequent resource utilization. This should motivate research to determine whether these differences are because of modifiable factors.

Impact of stent of ductus arteriosus and modified Blalock-Taussig shunt on pulmonary arteries growth and second-stage surgery in infants with ductus-dependent pulmonary circulation

Introduction

Ducts-dependent pulmonary circulation is spectrum of congenital heart diseases that need urgent intervention to augment pulmonary blood. Systemic to pulmonary shunt is the classical surgical management. Stenting of ductus arteriosus emerged in the last 2 decades as an alternative plausible intervention.

Objectives

To evaluate and compare the short and midterm effects of PDA stenting in compared to surgically placed shunt for augmentation of pulmonary blood flow looking to pulmonary artery (PA) branches growth, oxygen saturation and suitability for second stage repair.

Methods

We conducted this prospective study in Cardiac Surgical Intensive Care Unit. Cases were divided into "stent group" and "surgical shunt" group. Results were compared between two groups regarding oxygen saturation, mechanical ventilation duration, intensive care stay, mortality and morbidity. Growth of PA branches was assessed during follow up by echocardiograph. Nakata index score was calculated by angiogram before second stage surgery and was compared between both groups.

Results

43 patients were included. Forty-two cases were offered stent as initial management. 6/42 cases failed stenting (14%) and 3/42 (7%) required late BT shunt after PDA stenting. 10/43 cases ended up receiving BT shunt and were counted as "surgical shunt group". Stent group (33 cases) needed less mechanical ventilation (2.08 ± 0.65 vs.7.8 ± 4 days with p = 0.014), and less ICU stay compared with surgical shunt group (6.2 ± 1.02 vs. 14 ± 4.5 days, P = 0.009). Both groups achieved similar growth of pulmonary artery branches (p = 0.6 for Z score of left pulmonary artery and P = 0.8 for Z score for right pulmonary artery). Although "stent group" reached second stage surgery with lower O2 saturation 67.6 ± 4.6 vs. 80 ± 4.2 in "surgical shunt" group with P value = 0.0002). Majority of patients in both groups had some PA distortion and needed surgical reconstruction in main pulmonary artery or in its main branches during second stage repair. 3 cases (7.1%) died soon post stenting versus none in surgical shunt group (p = value 0.57).

Conclusions

In neonates with ductus-dependent pulmonary circulation PDA stenting can be introduced as safe first possible option to augment pulmonary blood flow with good outcome and suitable preparation for second stage palliation.

Hemodynamic of the patent ductus arteriosus in neonates with modified Blalock-Taussig shunts

BACKGROUND AND OBJECTIVE

Studying the hemodynamic effects of nonclosure of patent ductus arteriosus (PDA) on the modified Blalock-Taussig shunt (MBTS) is beneficial for surgical PDA management. In the present study, the effect of PDA on MBTS was investigated numerically. A series of parameters including energy loss, wall shear stress (WSS), and left/right Pulmonary artery (LPA/RPA) flow ratio were computed from simulations to analyze the hemodynamic effects of PDA on MBTS.

METHODS

To ensure the universality of the research conclusions, three typical models, including models with a well-developed RPA, a symmetrically-developed pulmonary artery(PA) and a well-developed LPA, were constructed based on patient-specific pre-surgery clinical data sets. A commercial CFD solver ANSYS-Fluent software was adopted for this study. A pressure-based solver for incompressible Newtonian flows, the K-omega based shear-stress-transport model and a second-order accurate numerical discretization scheme were employed for simulation.

RESULTS

Our results show that MBTS with nonclosure of PDA is accompanied by lower blood velocity, energy loss and WSS values at the MBT shunt; smaller vortex regions; higher oxygen content(Sao₂) and PA flow; and more uniform velocity distribution in the LPA and RPA than MBTS with closure of PDA. If the PDA was not closed when performing primary MBTS, a series of hemodynamic changes occurs during PDA closure in postoperative recovery: the energy loss, PA flow and Sao₂ decrease, while the oxygen delivery(Do2) and WSS values at the MBT shunt increase.

CONCLUSION

Nonclosure of PDA could provide a better hemodynamic environment and play an active role in preventing early acute shunt failure. It could be preferred for cases with very low PA overflow risk and may benefit patients with an underdeveloped myocardium due to its lower energy dissipation than PDA closure. However, excessive PA flow induced by nonclosure of PDA may result in a series of complications. Surgeon's decision-making process with respect to PDA management should consider the individual patient to achieve optimal postoperative recovery.

Transcatheter ductus arteriosus stenting in paediatric cardiology: Indications, results and perspectives

Stenting the arterial duct emerged in the early 1990s as an alternative to a variety of surgical interventions in neonates with a duct-dependent pulmonary or systemic circulation complex defect. Furthermore, palliative ductal stenting has been applied in older children with severe suprasystemic pulmonary arterial hypertension, as an alternative to surgical shunts, such as Potts anastomosis. Early results of this technique were discouraging, but by learning from the failures of the past, ductal stenting has become a reliable palliative therapy. In this review, we aim to describe the historical evolution of ductal stenting, its different clinical applications and outcomes, and future perspectives for this strategy in congenital cardiac catheterization.

Comparison of Outcomes at Time of Superior Cavopulmonary Connection Between Single Ventricle Patients With Ductal-Dependent Pulmonary Blood Flow Initially Palliated With Either Blalock-Taussig Shunt or Ductus Arteriosus Stent: Results From the Congenital Catheterization Research Collaborative

BACKGROUND

Patients with single ventricle anatomy and ductal-dependent pulmonary blood flow may be initially palliated with either modified Blalock-Taussig shunt (BTS) or ductus arteriosus stent (DAS). Comparisons of outcomes during the interstage period and at the time of superior cavopulmonary connection (SCPC) are lacking and may differ between palliation strategies.

METHODS

Infants with single ventricle anatomy and ductal-dependent pulmonary blood flow palliated with either DAS or BTS from 2008 to 2015 were reviewed across 4 centers. Interstage outcomes, and for those who had SCPC, anatomy, hemodynamics, and perioperative clinical outcomes were compared. Thirty-five patients with DAS and 136 patients with BTS were included.

RESULTS

At initial palliation, demographic, clinical variables, and pulmonary artery size were similar. Interstage death, transplant, or unplanned reintervention to treat cyanosis occurred in 25.7% of DAS and 35.8% of BTS, P=0.27. Reintervention was more common with DAS (48.6% versus 2.2%; P<0.001). Twenty-three DAS patients and 111 BTS patients underwent SCPC. Preoperative hemodynamics and overall pulmonary atresia growth were similar, although right pulmonary artery growth was better with DAS (change in z-score: 1.57 versus 0.65, P=0.026). SCPC intraoperative and postoperative courses were similar.

CONCLUSIONS

In patients with single-ventricle anatomy and ductal-dependent pulmonary blood flow, interstage outcomes, hemodynamics before SCPC, and acute postoperative outcomes were similar. Overall reintervention was more common in the DAS group, driven by more frequent planned reintervention. Unplanned reintervention, death, and transplant were similar. Both groups demonstrated good pulmonary atresia growth. DAS is a reasonable initial palliative alternative to BTS in select patients.

Pulmonary artery growth after Modified Blalock-Taussig shunt: A single center experience

OBJECTIVE

This study evaluates growth of pulmonary artery (PA) between different age groups after Modified Blalock-Taussig shunt (MBTS) based on a single center experience.

METHODS

We retrospective analyzed outcomes of 90 patients undergoing MBTS in our institute from January 1, 2010 to May 1, 2018. Patients were divided into three groups: Group 1, ≦2 months, Group 2, >2 months, ≦24 wmonths, Group 3, >24 months. The outcome included PA growth, overall survival rates and postoperative complications.

RESULTS

23 patients were involved in Group 1, while 49 in Group 2 and 18 in Group 3. The diameter of the PA, McGoon ratio, Nakata index and the oxygen saturation increased significantly after MBTS. Compared to pre-MBTS, there was no statistically significant increase of McGoon ratio in Group 3 after performing MBTS, but it witnessed less secondary cardiac surgery rate compared with Group 2 (11.11% vs. 48.98%, P = 0.005). Cumulative survival rates of three groups were 60.53%, 85.70%, 94.40% at 1 year; 60.53%, 78.30%, 87.75% at 3 years and 60.53%, 78.30%, 87.75% at 5 years. Multivariable analysis showed diastolic blood pressure <30 mmHg [OR 14.14 (1.92-104.32), P = 0.009], cardiopulmonary bypass use [OR 16.79 (2.05-137.67), P = 0.009] and single ventricle anomaly [OR 8.80 (1.18-65.54), P = 0.034] were predictors of perioperative mortality.

CONCLUSION

MBTS in our institute is a conventional and effective procedure for growth of PA especially for patients younger than 24 months. Patients with biventricular anomaly, no cardiopulmonary bypass use in surgery and relatively high postoperative diastolic blood pressure will likely offer a good prognosis.

Blalock-Taussig shunt versus patent ductus arteriosus stent as first palliation for ductal-dependent pulmonary circulation lesions: A review of the literature

BACKGROUND

Infants with ductal-dependent pulmonary blood flow (PBF) often undergo a palliative procedure to provide a stable source of PBF prior to definitive palliation or repair. In the current era, a surgical shunt or ductal stent is used to provide PBF. We aimed to review the current literature comparing ductal stents to surgical shunts.

METHODS AND RESULTS

Four small, single-center studies and two larger multicenter studies were identified comparing ductal stent to surgical shunt. Combined, these studies showed ductal stent resulted in similar or improved pulmonary artery growth, fewer complications, shorter length of stay, less diuretic use, and improved survival compared to surgical shunt. Despite inherent minor variability among the studies, ductal stent appears to be associated with more frequent reinterventions.

CONCLUSIONS

Surgical shunts remain essential to the care of these patients, but ductal stent is a reasonable alternative, and may provide some advantages in select patients with ductal-dependent PBF.

Anesthesia for high-risk procedures in the catheterization laboratory

Recent advances in catheterization and imaging technology allow for more complex procedures to be performed in the catheterization laboratory. A number of lesions are now amenable to a percutaneous procedure, eliminating or at least postponing the need for a surgical intervention. Due to the increase in the complexity of the procedures performed, the involvement of anesthesiologists and their close collaboration with the interventional cardiologists have increased. It is important to understand the physiology and pathophysiology of the patients and to anticipate the plans and the potential complications in order to manage them. We are witnessing a rise in the number of complex interventions in newborns and infants, such as balloon valvotomy (critical aortic stenosis, pulmonary stenosis), radio frequency perforation (of pulmonary atresia and intact ventricular septum), right ventricular outflow tract stenting (in Tetralogy of Fallot), ductal stenting (in some ductus-dependent pulmonary circulation), and combined with a surgical procedure (hybrid procedure for hypoplastic left heart syndrome). Multiple registries have been created in order to understand and improve outcomes of patients with congenital heart disease undergoing catheterization procedures and to develop performance and quality metrics, from which data regarding anesthetic-related risks can be extrapolated. Experienced personnel and a multidisciplinary team approach with direct communication among the team members is a must to ensure anticipation and management of critical events when they occur.

Percutaneous axillary artery approach for ductal stenting in critical right ventricular outflow tract lesions in the neonatal period

OBJECTIVES

We aimed to assess the experience using a percutaneous axillary artery approach for insertion of arterial ductal stents in patients with critical right ventricular outflow tract lesions at two tertiary pediatric cardiology centers.

BACKGROUND

Patent ductus arteriosus stenting is an accepted palliative alternative to BT shunts for neonates with critical right heart lesions. Access to tortuous ductus' may be challenging via the femoral artery, whereas the carotid artery presents a low risk of stroke. Recently, the axillary artery has been utilized for access in these patients.

METHODS

We performed a retrospective review of neonates who underwent stent placement or angioplasty using percutaneous axillary artery approach at two tertiary care centers from October 2016 to November 2018. Medical records were reviewed to ascertain demographic, clinical, and outcome data.

RESULTS

Axillary artery access was performed in 20 patients (16 primary ductal stents and 4 re-interventions) at a median (IQR) procedural weight of 3.4 (3-3.9) kg. Median (IQR) procedural time was 110 (75-150) min. The median (IQR) ICU stay and intubation times were 14 (0-94) hr and 5 (0-40) hr, respectively. There were three access-related vascular complications which were managed conservatively with no long-term effects. Two patients subsequently died due to non-procedure related causes.

CONCLUSIONS

Ductal stenting via a percutaneous axillary artery approach is a viable option in neonates with critical right ventricular outflow tract lesions. This approach provides an additional access site for PDA stenting which may be utilized in patients with vertical duct morphology.

Comparison Between Patent Ductus Arteriosus Stent and Modified Blalock-Taussig Shunt as Palliation for Infants With Ductal-Dependent Pulmonary Blood Flow

Background:

Infants with ductal-dependent pulmonary blood flow may undergo palliation with either a patent ductus arteriosus (PDA) stent or a modified Blalock-Taussig (BT) shunt. A balanced multicenter comparison of these 2 approaches is lacking.

Methods:

Infants with ductal-dependent pulmonary blood flow palliated with either a PDA stent or a BT shunt from January 2008 to November 2015 were reviewed from the 4 member centers of the Congenital Catheterization Research Collaborative. Outcomes were compared by use of propensity score adjustment to account for baseline differences between groups.

Results:

One hundred six patients with a PDA stent and 251 patients with a BT shunt were included. The groups differed in underlying anatomy (expected 2-ventricle circulation in 60% of PDA stents versus 45% of BT shunts; P =0.001) and presence of antegrade pulmonary blood flow (61% of PDA stents versus 38% of BT shunts; P <0.001). After propensity score adjustment, there was no difference in the hazard of the primary composite outcome of death or unplanned reintervention to treat cyanosis (hazard ratio, 0.8; 95% confidence interval [CI], 0.52–1.23; P =0.31). Other reinterventions were more common in the PDA stent group (hazard ratio, 29.8; 95% CI, 9.8–91.1; P <0.001). However, the PDA stent group had a lower adjusted intensive care unit length of stay (5.3 days [95% CI, 4.2–6.7] versus 9.19 days [95% CI, 7.9–10.6]; P <0.001), a lower risk of diuretic use at discharge (odds ratio, 0.4; 95% CI, 0.25–0.64; P <0.001) and procedural complications (odds ratio, 0.4; 95% CI, 0.2–0.77; P =0.006), and larger (152 mm 2 /m 2 [95% CI, 132–176] versus 125 mm 2 /m 2 [95% CI, 113–138]; P =0.029) and more symmetrical (symmetry index, 0.84 [95% CI, 0.8–0.89] versus 0.77 [95% CI, 0.75–0.8]; P =0.008] pulmonary arteries at the time of subsequent surgical repair or last follow-up.

Conclusions:

In this multicenter comparison of palliative PDA stent and BT shunt for infants with ductal-dependent pulmonary blood flow adjusted for differences in patient factors, there was no difference in the primary end point, death or unplanned reintervention to treat cyanosis. However, other markers of morbidity and pulmonary artery size favored the PDA stent group, supporting PDA stent as a reasonable alternative to BT shunt in select patients.

Duct Stenting Versus Modified Blalock-Taussig Shunt in Neonates With Duct-Dependent Pulmonary Blood Flow

Background:

Infants born with cardiac abnormalities causing dependence on the arterial duct for pulmonary blood flow are often palliated with a shunt usually between the subclavian artery and either pulmonary artery. A so-called modified Blalock-Taussig shunt allows progress through early life to an age and weight at which repair or further more stable palliation can be safely achieved. Modified Blalock-Taussig shunts continue to present concern for postprocedural instability and early mortality such that other alternatives continue to be explored. Duct stenting (DS) is emerging as one such alternative with potential for greater early stability and improved survival.

Methods:

The purpose of this study was to compare postprocedural outcomes and survival to next-stage palliative or reparative surgery between patients undergoing a modified Blalock-Taussig shunt or a DS in infants with duct-dependent pulmonary blood flow. All patients undergoing cardiac surgery and congenital interventions in the United Kingdom are prospectively recruited to an externally validated national outcome audit. From this audit, participating UK centers identified infants <30 days of age undergoing either a Blalock-Taussig shunt or a DS for cardiac conditions with duct-dependent pulmonary blood flow between January 2012 and December 31, 2015. One hundred seventy-one patients underwent a modified Blalock-Taussig shunt, and in 83 patients, DS was attempted. Primary and secondary outcomes of survival and need for extracorporeal support were analyzed with multivariable logistic regression. Longer-term mortality before repair and reintervention were analyzed with Cox proportional hazards regression. All multivariable analyses accommodated a propensity score to balance patient characteristics between the groups.

Results:

There was an early (to discharge) survival advantage for infants before next-stage surgery in the DS group (odds ratio, 4.24; 95% confidence interval, 1.37–13.14; P =0.012). There was also a difference in the need for postprocedural extracorporeal support in favor of the DS group (odds ratio, 0.22; 95% confidence interval, 0.05–1.05; P =0.058). Longer-term survival outcomes showed a reduced risk of death before repair in the DS group (hazard ratio, 0.25; 95% confidence interval, 0.07–0.85; P =0.026) but a slightly increased risk of reintervention (hazard ratio, 1.50; 95% confidence interval, 0.85–2.64; P =0.165).

Conclusions:

DS is emerging as a preferred alternative to a surgical shunt for neonatal palliation with evidence for greater postprocedural stability and improved patient survival to destination surgical treatment.

Stenting the complex patent ductus arteriosus in tetralogy of Fallot with pulmonary atresia: challenges and outcomes

Patent ductus arteriosus (PDA) stenting has gained acceptance for palliation in cyanotic congenital heart disease. The PDA in tetralogy of Fallot with pulmonary atresia (ToF-PA) arises, in the left aortic arch, from underneath the arch and connects to the proximal left pulmonary artery, often resulting in stenosis. The PDA is usually elongated and tortuous, making stent implantation challenging. Shorter duration of palliation, aggravation of branch pulmonary artery stenosis resulting in poor growth and difficulty at surgery makes ductal stenting controversial. Access via the carotid and axillary artery reduces complexity of the procedure and improves success, with recent data demonstrating good pulmonary artery growth. Advances in bioresorbable stents offer future promise and will likely resolve some controversies surrounding PDA stenting in ToF-PA.

Fate of Duct-Dependent, Discontinuous Pulmonary Arteries After Arterial Duct Stenting

Significant and balanced PA growth following arterial duct (AD) stenting has already been consistently reported in literature. However, to date, no data are available about the role of this approach as palliation of congenital heart disease with a duct-dependent discontinuous pulmonary artery (dPA). The aim of this study was to evaluate the fate of a dPA of ductal origin following trans-catheter AD stabilization. Angiographic PA evaluation was performed in seven patients submitted to neonatal AD stenting as palliative recruitment of dPA. Five patients showed discontinuity of one PA, while two patients had both PAs served by bilateral ducts. PA growth was evaluated as per the Nakata index, McGoon ratio as well as dPA (n = 9) versus heart-dependent PA (hPA; n = 5) size and z-score changes. AD stabilization was performed using coronary stents dilated to 3.2 ± 0.3 mm (median 3.4), with significant increase of O₂ saturation (from 83 ± 11 to 95 ± 5%, p < 0.02). Control angiography was performed 5.1 ± 2.8 months (median 6 months) after duct stenting, showing significant growth of the dPA (from 3.7 ± 1.0 to 7.6 ± 2.7 mm, p < 0.001; z-score from -0.7 ± 1.4 to 1.7 ± 2.2, p < 0.01). A trend toward better growth of the dPA as compared with the hPA was found (117 ± 87 vs. 54 ± 34%, p = NS). The final vessel size was still significantly different between the groups (dPA 7.6 ± 2.7 vs. hPA 11.9 ± 3.4 mm, p = 0.02), although the final z-score value did not significantly differ (dPA 1.7 ± 2.2 vs. hPA 3.8 ± 0.9 mm, p = NS). In conclusion, percutaneous AD stenting is effective in promoting a significant catch-up growth of duct-dependent dPA, being, therefore, advisable as a reliable alternative to surgical palliation.

Ductus arteriosus stenting: A promising percutaneous palliation in patients with duct-dependent pulmonary circulation

OBJECTIVES

We aimed to study the feasibility and outcomes of ductal stenting in patients with duct-dependent pulmonary blood flow (PBF).

METHODS

Duct-dependent hypoxic patients with confluent pulmonary artery (PA) branches were enrolled for ductal stenting and followed regularly.

RESULTS

Sixty patients, with a median age of 12 (1-1095) days and weight of 2.8 (2.2-8.9) kg, were enrolled. Median right PA (RPA) and left PA (LPA) Z-scores were -1.23 (-10.54 to 2.81) and -0.96 (-8.03 to 3.0), respectively. Mean narrowest ductal diameter was 1.73±0.57 mm and length was 12.78±3.32 mm. Sixty-four stents with mean diameter of 4.21±0.32 mm and length of 14.34±3.44 mm were deployed in 59 patients. The procedure was unsuccessful in one. Post-stenting mean oxygen saturation (SO₂) increased significantly from baseline of 68.88±7.47% to 90.43±6.04% (p<0001). Complications included pulmonary edema in one patient and acute stent occlusion in another. At a median follow-up of eight (2-14) months, mean SO₂ (80.04±7.54%) was significantly higher than baseline (p<0.0001). Median RPA and LPA Z-scores, 0.56 (-2.89 to 3.29) and -0.02 (-2.81 to 3.86), respectively, were significantly higher than baseline. Six patients required re-interventions (shunt in three and angioplasty in three). Six patients died, three due to sepsis and another three with worsened cyanosis due to impaired PBF, probably due to ductal occlusion.

CONCLUSION

Ductal stenting is an effective palliation in patients with duct-dependent PBF. It maintains adequate SO₂ and promotes balanced PA growth at mid-term follow-up.

Pulmonary artery growth after arterial duct stenting in completely duct-dependent pulmonary circulation

OBJECTIVE

Significant and balanced pulmonary artery (PA) growth following arterial duct (AD) stenting has already been reported in literature. However, no data are so far available about the role of this percutaneous approach in promoting PA growth in the case of congenital heart disease (CHD) with completely duct-dependent pulmonary blood flow (CDD-PBF). Aim of this study was to evaluate the effect of AD stenting in this pathophysiological setting.

METHODS

PA growth was evaluated as Nakata index and McGoon ratio as well as individual PA z-score changes in 49 patients submitted to neonatal AD stenting according to their pathophysiology (CDD-PBF (n=15) versus multiple PBF sources (n=34)).

RESULTS

Control angiography was performed 7.2±6.4 months (range 1-8, median 6) after AD stenting. In the whole population, significant and balanced PA growth was recorded (Nakata index+122±117%; left pulmonary artery (LPA) z-score +84±52%; right pulmonary artery (RPA) z-score +92±53% versus preprocedure, p<0.0001 for all comparisons). Percentage increase of global and branch vessel size was not significantly different in patients with CDD-PBF compared with those with multiple PBF sources (Nakata index 89±90% vs 144±124%; LPA z-score 63±40% vs 89±58%; RPA z-score 74±35% vs 100±57%, p=NS for all comparisons) as was final absolute PA size (Nakata index 237±90 vs 289±80 mm(2)/m(2), p=NS).

CONCLUSIONS

Percutaneous AD stenting was associated with significant and balanced PA growth in CHD with completely duct-dependent pulmonary circulation over a short-term follow-up. Thus, it may be considered as an alternative to surgical palliation in this subset of patients.

Dual-source computed tomography for evaluating pulmonary artery in pediatric patients with cyanotic congenital heart disease: Comparison with transthoracic echocardiography

PURPOSE

To evaluate the quantitative accuracy of dual-source computed tomography (DSCT) on measurements of pulmonary artery in pediatric patients with cyanotic congenital heart diseases (CCHDs) when compared with transthoracic echocardiography (TTE).

METHODS

Thirty-five patients (mean age: 27.88 ± 28.27 months) with CCHDs underwent DSCT and TTE for evaluating the diameter of the main pulmonary artery (MPA), right pulmonary artery (RPA), and left pulmonary artery (LPA). Surgical measurements were obtained and served as the reference standard. The agreement was tested by linear regression analysis, Pearson's correlation coefficient, and Bland-Altman analysis. The intra- and extracardiac malformations were also observed.

RESULTS

There was a markedly positive correlation between DSCT and surgical measurements of the MPA, RPA, and LPA (r=0.95-0.97; all p<0.001), although the overestimation of the measurements of MPA, RPA, and LPA (bias 0.15 ± 0.95, 0.31 ± 0.63 and 0.35 ± 0.68 mm, respectively) was observed. However, there was a moderate correlation between TTE and surgical measurements of MPA, RPA, and LPA (r=0.61-0.84; all p<0.001), and the underestimation of the measurements of MPA, RPA, and LPA (bias-1.20 ± 1.69, -1.80 ± 1.77, and -1.50 ± 2.30 mm, respectively) was observed. In addition, DSCT was more efficient in finding associated malformations than TTE (40/40 vs. 33/40).

CONCLUSIONS

As a reliable, noninvasive and radiation-save imaging modality, DSCT can provide more accurate pulmonary artery measurements than TTE in cardiac surgical procedures.

Fate of Hypoplastic Pulmonary Arteries After Arterial Duct Stenting in Congenital Heart Disease With Duct-Dependent Pulmonary Circulation

OBJECTIVES

This study sought to evaluate the impact of arterial duct (AD) stenting in promoting catch-up growth of hypoplastic pulmonary artery (PA) tree in congenital heart disease with duct-dependent pulmonary circulation (CHD-DPC).

BACKGROUND

Significant and balanced PA growth following AD stenting has already been consistently reported in the literature. However, no data are so far available about the role of this approach in severe PA hypoplasia, which significantly impacts the risk of surgical repair.

METHODS

Pre-surgical angiographic PA evaluation was performed in 45 patients with confluent PAs submitted to neonatal AD stenting as palliation of CHD-DPC. PA growth was evaluated as Nakata Index and McGoon ratio as well as individual PA z-score changes, both in the whole population and according to the original vessel size (Nakata Index <100 mm(2)/m(2), Group I [n = 15] vs. Nakata Index >100 mm(2)/m(2), Group II [n = 30]).

RESULTS

Control angiography was performed 7.5 ± 6.5 months (median 6 months) after duct stenting, showing significant and balanced PA growth. The Nakata Index increased from 143 ± 73 mm(2)/m(2) to 270 ± 88 mm(2)/m(2) (124 ± 118%, p < 0.0001); left PA z-score from -0.7 ± 1.7 to 1.0 ± 1.4; right PA z-score from -0.6 ± 1.3 to 1.2 ± 1.3 (p < 0.0001 for both comparisons). Group I showed a greater increase of global PA growth (Nakata Index increase 227 ± 141% vs. 72 ± 57%, p < 0.001) as compared with Group II. Final PA size did not significantly differ between the groups (246 ± 105 mm(2)/m(2) vs. 282 ± 78 mm(2)/m(2), p = NS).

CONCLUSIONS

Percutaneous AD stenting is highly effective in promoting a significant and balanced catch-up growth of diminutive PAs, being therefore advisable in this subset of patients as a reliable alternative to surgical palliation.

Stenting of the right ventricular outflow tract in a symptomatic newborn with tetralogy of Fallot

This case describes a successful percutaneous stent implantation to critical stenosis of the right ventricle outflow tract in a female neonate with tetralogy of Fallot. At the time of the procedure she had poor development of the pulmonary arteries (McGoon and Nakata index 1.45 and 120, respectively). Stent implantation ensured an immediate increase in oxygen saturation level, and the physiological pulsating blood inflow caused good development of the pulmonary arteries during 12 months of follow up (McGoon 2.5; Nacata Index 436). After this time she was qualified for surgery and underwent surgical correction without using a patch or conduit implantation.