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

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

Grozdanov D, Osawa T, Borgmann K, Schaeffer T, Staehler H, Di Padua C, Heinisch PP, Piber N, Georgiev S, Hager A, Ewert P, Hörer J, Ono M. Eur J Cardiothorac Surg. 2024 Mar 1;65(3):ezae011. doi: 10.1093/ejcts/ezae011.PMID: 38212978

Take home points:

  • In patients with single ventricle physiology and ductal-dependent pulmonary blood flow, initial palliation with either a surgical systemic-to-pulmonary artery shunt or interventional ductal stenting had comparable survival rates, with no significant difference in the probability of reaching stage II and III palliation.
  • Patients undergoing ductal stenting experienced shorter ICU and hospital stays, while having higher rates of acute complications, needing more frequent reinterventions.

Commentry from Dr. Milan Prsa (Switzerland, Europe), section editor of Congenital Heart Disease Interventions Journal Watch :

In patients with single ventricle (SV) physiology and ductal-dependent pulmonary blood flow (DD-PBF), an initial palliation during the neonatal period is necessary to establish a stable source of PBF. This can be achieved through a surgical systemic-to-pulmonary artery shunt (SPS) or percutaneous ductal stenting (DS). The authors sought to compare survival rates between SPS and DS in patients with SV physiology and DD-PBF. Additionally, they aimed to compare the two groups in terms of hospital recovery, rate of complications, pulmonary artery (PA) development and outcomes for stage II and stage III palliation.

This was a retrospective, observational study conducted at a single center from 2009 to 2022. A total of 130 patients were identified, with 81 undergoing SPS (62 modified Blalock-Taussig shunt and 19 central aortopulmonary shunt) and 49 undergoing DS as their initial palliation. The only significant difference between the groups was more patients with pulmonary atresia and intact ventricular septum were palliated with DS (22.4% vs. 9.9%, p = 0.049).

The results showed comparable survival rates between the two groups, with no significant difference in reaching stage II or stage III palliation. Patients with DS had significantly shorter ICU and overall hospital stays compared to SPS (median 1 vs. 7 days in the ICU; 7 vs. 17 days in the hospital). Acute complications, including stent dysfunction and dislocation, were more common in the DS group (20.4% vs. 6.2% in the SPS group), with all 10 of these patients in the DS group needing a SPS. Pulmonary artery growth was generally similar between the two groups, though patients with DS showed a lower ratio of left-to-right PA index compared to those with SPS, indicating potentially less balanced PA development.

Despite its shortcomings as a single-center retrospective review with inherent patient-level differences, this study supports the use of DS as a viable initial palliative option for patients with SV physiology and DD-PBF, particularly given the reduced hospitalization time and comparable survival rates to SPS. However, clinicians should weigh the benefits of shorter ICU and hospital stays against the potentially higher risk of reintervention associated with DS, including emergent conversion to SPS. The study also underscores the need for a prospective randomized trial to determine if one palliative approach offers a clear therapeutic advantage. Hopefully, the future large multicenter COMPASS trial will settle the debate.1

References

  1. Petit CJ, Romano JC, Zampi JD, et al. Rationale and Design of the Randomized Comparison of Methods for Pulmonary Blood Flow Augmentation: Shunt Versus Stent (COMPASS) Trial: A Pediatric Heart Network Study. World Journal for Pediatric and Congenital Heart Surgery. 2024;0(0). doi:10.1177/21501351241266110
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