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<p>The Blalock Taussig Thomas Shunt (BTTS) is a palliative procedure for children with congenital heart disease (CHD). This operation may involve significant morbidity and mortality, and its effect on pulmonary arteries has been ambivalent. Ductal stenting is an alternative option. We aimed to evaluate pulmonary artery growth and clinical course following an operative BTTS as compared to percutaneous ductal stenting. Retrospective review of 92 patients who underwent BTTS and 34 patients who underwent percutaneous ductal stenting at the Sheba Medical Center between the years 2014–2021. Clinical data were extracted from patient medical files for assessment of morbidity, mortality, and procedural complications. Echocardiograms and angiography preformed before, six months and two years following the procedure were evaluated for pulmonary artery assessment. The groups did not differ significantly in terms of demographic findings, degree of complicated cases, or presence of antegrade pulmonary blood flow before the procedure. PDA stent patients had shorter ICU length of stay (median 6&#xa0;days (IQR 3–8) vs. 9 (7–17); <i>p</i> &lt; 0.001), hospitalization (7&#xa0;days (3–9) vs. 11 (7–18); <i>p</i> &lt; 0.001), and ventilation (0.25&#xa0;days (0.25–2) vs. 3 (1–5); <i>p</i> &lt; 0.001). The stent group needed minimal to no ionotropic support on the days 0, 1, and 2 after intervention (vasoactive-inotropic score (VIS) on the day of the procedure 0 (0–0.5)&#xa0;in the stent group vs. 8.7 (2.5–14.2)&#xa0;in the shunt group, VIS on day one 0 (0–2.5) vs. 7.7 (2.5–14.2), VIS on postoperative day two 0 (0–2.1) vs. 5 (0–11); <i>p</i> &lt; 0.001). Pulmonary artery stenosis was present in 58.8% of PDA stents before intervention vs. 33.7% of BTTS; <i>p</i> = 0.01), yet the PDA stent group showed improved pulmonary artery growth with larger pulmonary artery diameter at both 6&#xa0;months (McGoon ratio 1.9 (1.7–2.2) vs. 1.7 (1.4–1.9); <i>p</i> = 0.001) and 2&#xa0;years after intervention (McGoon ratio 2.2 ± 0.5 vs. 1.8 ± 0.4; <i>p</i> = 0.004). Mortality in the ICU was significantly higher in the BTTS group 13 (14.1%) versus 1 (2.9%) in the PDA stent group (<i>p</i> &lt; 0.001), and even higher if BTTS was performed with cardiopulmonary bypass 6 (19.4%) vs PDA stenting 1 (2.9%) (<i>p</i> &lt; 0.05). Pulmonary artery assessment showed that late surgical pulmonary artery repair after a PDA stent may be preferable to arterioplasty performed early with an initial BTTS (0% vs. 100% qualitative stenosis, <i>p</i> = 0.005). PDA stenting results in significantly fewer complications and lower mortality than BTTS, even if surgery is performed with cardiopulmonary bypass. In addition, PDA stenting allows good and in some cases more favorable mid-term pulmonary artery growth, particularly for patients whose anatomy necessitates surgical pulmonary arterioplasty. PDA stenting may therefore be a better option than BTTS for palliation in duct dependent pulmonary circulation, even for infants with pulmonary artery stenosis, whose initial palliation is a PDA stent followed by pulmonary arterioplasty later in infancy.</p>

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PDA Stenting May Be a Favorable Alternative to BTT Shunt Regarding Acute Complications and Mid Term Pulmonary Artery Growth

  • 期刊论文

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  • 发表日期：

    2025年4月11日

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  • Paz Rimoni,
  • Ori Stern,
  • Gur Mainzer,
  • Uriel Katz,
  • Amir Vardi,
  • David Mishali,
  • Sharon Borik Chiger

摘要

The Blalock Taussig Thomas Shunt (BTTS) is a palliative procedure for children with congenital heart disease (CHD). This operation may involve significant morbidity and mortality, and its effect on pulmonary arteries has been ambivalent. Ductal stenting is an alternative option. We aimed to evaluate pulmonary artery growth and clinical course following an operative BTTS as compared to percutaneous ductal stenting. Retrospective review of 92 patients who underwent BTTS and 34 patients who underwent percutaneous ductal stenting at the Sheba Medical Center between the years 2014–2021. Clinical data were extracted from patient medical files for assessment of morbidity, mortality, and procedural complications. Echocardiograms and angiography preformed before, six months and two years following the procedure were evaluated for pulmonary artery assessment. The groups did not differ significantly in terms of demographic findings, degree of complicated cases, or presence of antegrade pulmonary blood flow before the procedure. PDA stent patients had shorter ICU length of stay (median 6 days (IQR 3–8) vs. 9 (7–17); p < 0.001), hospitalization (7 days (3–9) vs. 11 (7–18); p < 0.001), and ventilation (0.25 days (0.25–2) vs. 3 (1–5); p < 0.001). The stent group needed minimal to no ionotropic support on the days 0, 1, and 2 after intervention (vasoactive-inotropic score (VIS) on the day of the procedure 0 (0–0.5) in the stent group vs. 8.7 (2.5–14.2) in the shunt group, VIS on day one 0 (0–2.5) vs. 7.7 (2.5–14.2), VIS on postoperative day two 0 (0–2.1) vs. 5 (0–11); p < 0.001). Pulmonary artery stenosis was present in 58.8% of PDA stents before intervention vs. 33.7% of BTTS; p = 0.01), yet the PDA stent group showed improved pulmonary artery growth with larger pulmonary artery diameter at both 6 months (McGoon ratio 1.9 (1.7–2.2) vs. 1.7 (1.4–1.9); p = 0.001) and 2 years after intervention (McGoon ratio 2.2 ± 0.5 vs. 1.8 ± 0.4; p = 0.004). Mortality in the ICU was significantly higher in the BTTS group 13 (14.1%) versus 1 (2.9%) in the PDA stent group (p < 0.001), and even higher if BTTS was performed with cardiopulmonary bypass 6 (19.4%) vs PDA stenting 1 (2.9%) (p < 0.05). Pulmonary artery assessment showed that late surgical pulmonary artery repair after a PDA stent may be preferable to arterioplasty performed early with an initial BTTS (0% vs. 100% qualitative stenosis, p = 0.005). PDA stenting results in significantly fewer complications and lower mortality than BTTS, even if surgery is performed with cardiopulmonary bypass. In addition, PDA stenting allows good and in some cases more favorable mid-term pulmonary artery growth, particularly for patients whose anatomy necessitates surgical pulmonary arterioplasty. PDA stenting may therefore be a better option than BTTS for palliation in duct dependent pulmonary circulation, even for infants with pulmonary artery stenosis, whose initial palliation is a PDA stent followed by pulmonary arterioplasty later in infancy.