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

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Abstract

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.

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Most cited references 25

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

Bryan Goldstein, Christopher J Petit, Andrew C Glatz … (2018)

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.

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Duct Stenting Versus Modified Blalock-Taussig Shunt in Neonates With Duct-Dependent Pulmonary Blood Flow: Associations With Clinical Outcomes in a Multicenter National Study.

Vikram Kudumula, Anthony Hermuzi, Akintayo Adesokan … (2018)

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.

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A new method for the quantitative standardization of cross-sectional areas of the pulmonary arteries in congenital heart diseases with decreased pulmonary blood flow.

H. Kurosawa, M Nakazawa, A Takao … (1984)

A new angiographic method for quantitative standardization of cross-sectional area of bilateral pulmonary arteries, the PA-index, and retrospective analysis of the PA-index in different types of operative procedures are presented. This study included 40 subjects in the normal control group, 46 patients in the tetralogy group, 26 patients in the Rastelli group, and 15 patients in the Fontan group. The normal value of the PA-index was 330 +/- 30 mm2/BSA and was consistent in a wide range of body surface areas from infancy to adolescence. The PA-index in the tetralogy and Rastelli groups ranged from 100 to 400 mm2/BSA. There were no early deaths in the tetralogy group, but the incidence of low cardiac output was higher in patients with a smaller PA-index, especially when the PA-index was less than 150 mm2/BSA. Low cardiac output was more severe in the Rastelli group. The operative mortality was significantly affected by the PA-index. In the Rastelli group, all of the patients with a PA-index of less than 200 mm2/BSA died, whereas the mortality rate in patients with a PA-index of more than 200 was only 6% (p less than 0.01). The mortality rate was not influenced by any other factors, such as aortic cross-clamp time or age at operation. In the Fontan group, two patients with a PA-index of less than 250 mm2/BSA died of severe heart failure, and 12 of 13 patients with a PA-index of more than 250 survived (p less than 0.01). Our results indicated the validity of the PA-index in predicting the postoperative prognosis of the various entities. In tetralogy, all patients with a PA-index over 100 mm2/BSA can undergo correction safely; in Rastelli operation, those with a PA-index under 200 should have a palliative procedure first, whereas those with a PA-index over 250 can be considered good candidates for the Fontan procedure. The PA-index may also serve a useful guide in comparing surgical results from different institutions with patients having anomalies of varying severity.