Duct Stenting vs. Blalock Shunt for Infant Palliation

Study Questions:

What are the outcomes of duct stenting (DS) as compared with the modified Blalock Taussig shunt (MBTS) for infants with ductal-dependent pulmonary blood flow?

Methods:

A retrospective cohort study was performed using the National Congenital Heart Disease Audit in the United Kingdom. Infants <30 days of age undergoing a DS or MBTS between January 2012 and December 2015 were studied. The primary outcome was survival to next stage surgery (either further palliation or complete repair). Secondary outcomes included 30-day survival, survival to discharge, 1-year survival, and need for post-procedure extracorporal membrane oxygenation (ECMO).

Results:

Survival to discharge for infants pre-next surgery was higher in the DS group (odds ratio [OR], 4.24; 95% confidence interval [CI], 1.37-13.14; p = 0.012). There was a decreased risk for ECMO post-procedure in the DS group (OR, 0.22; 95% CI, 0.05-1.05; p = 0.058). There was a reduced risk of death pre-repair in patients undergoing DS (hazard ratio [HR], 0.25; 95% CI, 0.07-0.85; p = 0.026), but an increased risk of re-intervention (HR, 1.5; 95% CI, 0.85-2.64; p = 0.165).

Conclusions:

The authors concluded that DS is emerging as a preferred alternative to a surgical shunt for neonatal palliation in patients with ductal-dependent pulmonary blood flow.

Perspective:

This study retrospectively assessed the outcomes for patients with ductal-dependent pulmonary blood flow after ductal stenting as compared with surgical shunt placement. The study shows a survival benefit in patients undergoing duct stent placement, although there was a higher rate of re-intervention, particularly for additional interventions on the stented duct. This study complements a recently published study from the United States, which similarly investigated this issue. The US study showed similar survival outcomes for patients undergoing DS as compared with MBTS, although morbidity parameters such as intensive care unit length of stay were superior in patients undergoing the transcatheter procedure. These studies demonstrate an emerging role for DS in the initial palliation of patients with duct-dependent pulmonary blood flow. The primary limitation is the retrospective, nonrandomized design of the studies, which leave room for selection bias for patients who may be better candidate for a particular procedure.

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, Extracorporeal Membrane Oxygenation, Heart Defects, Congenital, Hemodynamics, Infant, Infant, Newborn, Palliative Care, Risk, Stents, Survival Analysis, Treatment Outcome


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