Use of the ductal curvature index to assess the risk of ductal stenting in patients with duct-dependent pulmonary circulation

Abstract

Background: To evaluate whether a quantitative curvature threshold can contribute to risk stratification of ductal stenting in patients with a duct-dependent pulmonary circulation (DDPC).Methods: A single-center retrospective analysis was performed. The ductal curvature index (DCI) was calculated in 71 patients with DDPC. The ducts were divided into four classes based on quartile thresholds of DCI: class I (≤0.12), class II (0.13-0.33), class III (0.34-0.44), and class IV (≥0.45). The primary outcome of this study was defined as free from all of the following: (I) intervention related death, (II) need of unplanned surgery (III) need of unplanned pulmonary valve (PV) perforation with stent in right ventricular outflow tract (RVOT), and (IV) intervention related permanent complications.Results: Eighty percent of patients in class IV (DCI ≥0.45) failed to achieve the primary outcome; odds ratio (OR) 9 and 95% confidence interval (CI): 3.7-21.4 compared to 26.6% in all classes with DCI <0.45. 66.7% of these patients needed unplanned surgery or PVP with RVOT stent; OR 12.4 (95% CI: 4-39). 80% of major complications were observed in class IV (P<0.01). Need of pulmonary arterioplasty was in class IV 53.3%; OR 3.3 (95% CI: 1.5-7.1).Conclusions: DCI can be useful to guide the clinical decision-making in patients with torqued ducts.Patients with a DCI ≥0.45 belong to a high-risk group, in which ductal stenting is associated with an elevated risk for early surgery or unplanned re-intervention.

Duct Stenting vs. Modified Blalock-Taussig Shunt: New Insights Learned From High-Risk Patients With Duct-Dependent Pulmonary Circulation

“…All published comparisons between MBTs and DS were performed regardless of the complexity of ductal morphology ( 10 – 13 ). In a previous study published in 2021 ( 9 ), the results of our center showed that the patients with an increased ductal tortuosity and ductal curvature index (equal to or more than 0.45) have to be classified as the high-risk patients for duct stenting. The primary outcome in these patients was achieved in only 20% of them.…”

“…Contrary to the results of the previous studies, the current results showed that the need for PA-plasty was higher in the DS group. This can be explained by the highly tortuous ducts associated with a resulting functional pulmonary stenosis in our DS cohort ( 9 ).…”

“…Based on our previous study published in 2021 ( 9 ) high-risk patients for stenting were defined as patients having DCI equal or higher than 0.45.…”

“…Additionally, two subgroups were established to study more specifically and for the first time the outcome between DS and MBTs in special cases. The first subgroup includes the patients who belong to the high-risk group for stenting ( 9 ) with DCI >0.45 ( n = 32) and the second includes the patients who have PA-IVS and coronary sinusoids ( n = 13). All patients with an additional pulmonary blood supply like patients with PA and major aorta pulmonary collateral Arteries (MAPCAs) were excluded from this study, as well as patients with pulmonary stenosis who have significant antegrade pulmonary perfusion.…”

“…The efficacy of DS as an alternative to MBTs has been documented in multiple studies (6,7). The mortality rate, need for ECMO, and procedure-related complications were reported to be higher in the MBTs group compared to the DS group due to post-operative hemodynamic instability (8)(9)(10). Thus, in patients with PA and DDPC, the DS has become the preferred method of choice in some centers.…”