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

Abstract

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 artery 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 artery growth. DAS is a reasonable initial palliative alternative to BTS in select patients.

Transition to Ductal Stenting for Single Ventricle Patients Led to Improved Survival: An Institutional Case Series

“…We acknowledge that our results may not be generalizable to centers that have excellent outcomes after SPS placement in single ventricle patients. For instance, our SPS patients experienced interstage mortality that was significantly higher than the 12.7% reported in a 2019 multicenter study by Meadows et al 16 To explain this difference, we first performed a critical review of our patient operative records which revealed no obvious technical issues. One possible contributing factor is poor adherence to anticoagulation in earlier SPS patients, although these data were not evaluated.…”

“…Similar trends are reported in other studies that assessed ECMO requirement. 12,16,23 Furthermore, of the nine SPS patients requiring ECMO, seven did not survive to S2P. This suggests that ECMO requirement following single ventricle palliation may be a predictor of interstage mortality.…”

“…Regarding interstage reintervention in ddPBF patients, some studies indicate a higher risk of reinterventions after DS, 12,14 while other studies show no difference between groups. 16,23 However, these data must be interpreted with respect to average interstage durations. For instance, some studies have statistically different interstage durations between DS and SPS groups which precludes accurate comparison of reintervention rates.…”

“…While several studies have been published comparing DS to SPS in populations of single ventricle and biventricular patients (ie, mixed populations), [12][13][14][15] only two analyses compare these interventions exclusively in single ventricle patients. 16,17 Given that the initial palliation, postprocedure hospital stay, and interstage periods are high-risk periods for neonates with expected single ventricle circulation, there is a need for more outcomes data in this patient population. 18 Historically, our center experienced poor outcomes after SPS placement in single ventricle patients.…”

Commentary: Ductal stenting for ductal-dependent pulmonary blood flow: Time for an exclusive club to expand its membership?

“…Notably, both strategies produced similar candidates for superior cavopulmonary connection, because preoperative hemodynamics and pulmonary artery growth did not differ. 4 These findings suggest greater nuance is needed when considering the source of pulmonary blood flow in patients with SV disease. Although not clearly associated with lower morbidity and mortality, DS would include patients with SV physiology who are more tenuous and less able to tolerate the stress of cardiopulmonary bypass and the risk of shunt thrombosis.…”