Callegari A, Logoteta J, Knirsch W, Cesnjevar R, Dave H, Kretschmar O, Quandt D.Pediatr Cardiol. 2023 Oct;44(7):1495-1505. doi: 10.1007/s00246-023-03229-3. Epub 2023 Jul 15.PMID: 37453932
Take Home Points
- PA stent implantation early after BDCPC is safe and feasible
- Single RV, larger neo-ascending aorta, and small LPA at the pre-BDCPC cath are independent risk factors for PA-stent implantation post-BDCPC
- PA diameters after PA-stent implantation and stent dilation show symmetric growth compared to the contralateral side
Commentary from Dr. Jonathon Hagel (C.S. Mott Children’s Hospital, University of Michigan)
Branch pulmonary artery (PA) stenosis in the single ventricle population remains a common post operative problem that is often addressed in the cath lab. The authors sought to identify patients at risk of PA-stent implantation after bidirectional cavopulmonary connection (BDCPC) surgery. They secondarily sought to determine if PA growth would be similar in a PA-stented group compared to a group that did not require PA-stent implantation at the time of the pre-TCPC (total cavopulmonary connection) surgery.
A single center, retrospective, longitudinal analysis of all patients who underwent single ventricle palliation with pre-BDCPC and pre-TCPC catheterizations were included in this study. From 2006 to 2021, 136 patients met the inclusion criteria of which 56 (41%) were female and single right ventricle (RV) physiology was present in 69 (51%). PA-stent implantation was performed in 40 (29%) patients and of these 37 (92.5%) required LPA stent implantation. LPA compression from the neo-ascending aorta was present in 16/40 (40%) of cases and was the most common etiology necessitating stent implantation.
On logistic regression analysis, single RV patients were more likely (OR 0.41, p=0.05) to need PA-stent implantation compared to single LV patients. Smaller LPA diameter (OR 0.89, p=0.03) and larger diameter of the neo-ascending aorta pre-BDCPC (OR 1.05, p=0.001) were associated with an increased likelihood of PA-stent implantation post-BDCPC. Overall, PA diameters were smaller in the PA-stent group but when comparing the pre-BDCPC and pre-TCPC absolute PA diameters among both groups, there was no difference in PA growth.
The authors conclude that PA-stent implantation early after the BDCPC surgery is safe and ensures symmetrical pulmonary flow and growth of the hilar intrapulmonary vessels. They further extrapolate that based on their findings, patients at higher risk of needing PA-stent implantation i.e. single RV, smaller LPA at pre-BDCPC cath, and dilated neo-ascending aorta, may be good candidates for exit angiography after the BDCPC surgery. The authors acknowledge that flow differential was not quantitatively assessed by cardiac MRI or lung perfusion scan and such flows may have a greater impact on the growth of PAs. Lastly, as this is a single institution study, frequency and timing of intervention may represent an institutional approach to care making generalizability limited to other surgical or interventional approaches.
