PDA Stent vs. BT Shunt as Palliation for Infants

Study Questions:

What is the comparative efficacy and safety of the patent ductus arteriosus (PDA) stent and Blalock-Taussig (BT) shunt as palliative options for infants with ductal-dependent pulmonary blood flow?

Methods:

The investigators reviewed infants with ductal-dependent pulmonary blood flow, palliated with either a PDA stent or BT shunt from January 2008 to November 2015, from the four member centers of the Congenital Catheterization Research Collaborative. Outcomes were compared using propensity score adjustment to account for baseline differences between groups.

Results:

A total of 106 PDA stent and 251 BT shunt patients were included. The groups differed in underlying anatomy (expected two-ventricle circulation in 60% of PDA stents vs. 45% of BT shunts, p = 0.001), and presence of antegrade pulmonary blood flow (61% of PDA stents vs. 38% of BT shunts, p < 0.001). After propensity-score adjustment, there was no difference in the hazard of the primary composite outcome of death or unplanned reintervention to treat cyanosis (hazard ratio [HR], 0.8; 95% confidence interval [CI], 0.52-1.23; p = 0.31). Other reinterventions were more common in the PDA stent group (HR, 29.8; 95% CI, 9.8-91.1; p < 0.001). However, the PDA stent group had a lower adjusted intensive care unit (ICU) length of stay (5.3, 95% CI, 4.2-6.7 vs. 9.19, 95% CI, 7.9-10.6 days; p < 0.001), a lower risk of diuretic use at discharge (odds ratio [OR], 0.4; 95% CI, 0.25-0.64; p < 0.001) and procedural complications (OR, 0.4; 95% CI, 0.2-0.77; p = 0.006), and larger (152, 95% CI, 132-176 vs. 125, 95% CI, 113-138 mm2/m2; p = 0.029) and more symmetric (symmetry index, 0.84; 95% CI, 0.8-0.89 vs. 0.77, 95% CI, 0.75-0.8; p = 0.008) pulmonary arteries at the time of subsequent surgical repair or last follow-up.

Conclusions:

The authors concluded that there was no difference in the primary endpoint, death or unplanned reintervention to treat cyanosis, between PDA stent and BT shunt.

Perspective:

This study reports that after adjustment for patient factors in those with ductal-dependent pulmonary blood flow, there was no difference between PDA stent and BT shunt in the hazard of the primary outcome, a composite of death or unplanned reintervention to treat cyanosis. However, those treated with a PDA stent had a lower risk of procedural complications, shorter ICU length of stay, lesser use of diuretics, and larger and more symmetric pulmonary arteries prior to their subsequent surgical repair or palliation. These findings would support PDA stent placement as a preferable palliative strategy to BT shunt placement in appropriate patients with ductal-dependent pulmonary blood flow, especially in experienced centers where it can be performed safely and effectively. Additional research is indicated to identify specific anatomic characteristics of patients that would most likely benefit from PDA stent placement.

Clinical Topics: Cardiac Surgery, Congenital Heart Disease and Pediatric Cardiology, Invasive Cardiovascular Angiography and Intervention, Cardiac Surgery and CHD & Pediatrics, Congenital Heart Disease, CHD & Pediatrics and Interventions, CHD & Pediatrics and Quality Improvement, Interventions and Structural Heart Disease

Keywords: Blalock-Taussig Procedure, Cardiac Surgical Procedures, Catheterization, Cyanosis, Diuretics, Ductus Arteriosus, Patent, Heart Defects, Congenital, Infant, Pulmonary Artery, Stents, Treatment Outcome


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