|Year : 2023 | Volume
| Issue : 1 | Page : 11-16
Comparison of patent ductus arteriosus stenting and Blalock-Taussig shunt in ductal dependent blood flow congenital heart disease and decreased pulmonary blood flow
Mehdi Ghaderian1, Samin Behdad2, Masoume Mokhtari1, Ladan Salamati1
1 Pediatric Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
2 Cardiac Rehabilitation Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
|Date of Submission||14-Sep-2022|
|Date of Acceptance||18-Jan-2023|
|Date of Web Publication||23-Feb-2023|
Dr. Samin Behdad
Cardiac Rehabilitation Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Congenital ductal-dependent cyanotic congenital heart disease (CHD) is a group of diseases that require early intervention during early infancy or the neonatal period. In this study, we compared the effectiveness, safety, and side effects of stenting patent ductus arteriosus versus a modified Blalock-Taussig (BT) shunt.
Materials and Methods: Thirty-six neonates and infants with cyanotic CHD who were <6 months old and were not suitable for complete surgery were admitted to Chamran Hospital in Isfahan and enrolled in this prospective longitudinal cross-sectional study. Ductal stenting (DS) was performed in 18 patients and BT shunt in 18 patients. Data were collected and compared in these patients.
Results: Age, height, and weight were lower in the DS group compared to the shunt group (1.28 ± 0.46 vs. 2.50 ± 0.51 months, 53.22 ± 1.80 vs. 56.11 ± 1.67 cm, 3.38 ± 0.45 vs. 4.98 ± 0.57 kg, respectively P < 0.001). The duration of the intensive care unit stay as well as hospital stay in patients in the DS group was much shorter than the shunt group (1.33 ± 0.68 vs. 2.83 ± 0.70 days, 3.33 ± 0.68 vs. 9.55 ± 0.51, P < 0.001, respectively). In both groups, the diameter of the pulmonary branches increased after the procedure compared to before the procedure (P < 0.001). Furthermore, the patient's hemoglobin was significantly decreased compared to before the procedure (P < 0.001). In both groups, one patient died in the postprocedure period. In ductal stent group one patient died in catheterization lab and in shunt group died 48 hours after surgery. There was no significant difference in postprocedural complications between the two groups.
Conclusion: Duct stents can be used as an effective and safe method in duct-dependent cyanotic CHD patients who are not suitable candidates for complete surgery. As operators become proficient, this method can be a good alternative to BT shunts with fewer complications.
Keywords: Blalock-Taussig shunt, cyanotic congenital heart disease, patent ductus arteriosus, stenting
|How to cite this article:|
Ghaderian M, Behdad S, Mokhtari M, Salamati L. Comparison of patent ductus arteriosus stenting and Blalock-Taussig shunt in ductal dependent blood flow congenital heart disease and decreased pulmonary blood flow. Heart Views 2023;24:11-6
|How to cite this URL:|
Ghaderian M, Behdad S, Mokhtari M, Salamati L. Comparison of patent ductus arteriosus stenting and Blalock-Taussig shunt in ductal dependent blood flow congenital heart disease and decreased pulmonary blood flow. Heart Views [serial online] 2023 [cited 2023 Mar 26];24:11-6. Available from: https://www.heartviews.org/text.asp?2023/24/1/11/370267
| Introduction|| |
Cyanotic congenital heart disease (CHD), due to inadequate pulmonary blood flow, leads to clinical cyanosis and low blood oxygen saturation in newborn. Medical and surgical advances have dramatic outcomes such that most infants with CHD have options for interventions that allow survival. To treat these patients, the use of palliative methods to increase pulmonary blood flow and increase blood oxygen saturation is necessary at birth or early infancy. Following these procedures, different type of CHD requires a total surgical corrective procedure in appropriate conditions.
Surgical procedures, such as Blalock-Taussig shunts (BTSs), have long been widely used in the treatment of patients with decreased pulmonary blood flow. However, high mortality and morbidity of patients, especially in low birth weight infants, and its associated complications such as shunt obstruction, shunt stenosis, deviation and distortion in pulmonary arteries, asymmetric growth of pulmonary artery (PA) branches, pleural effusion, phrenic nerve injury, vocal cord palsy have led to the invention of interventional methods.,,,,
Ductus stenting (DS) of a patent ductus arteriosus (PDA) to prevent its closure is one of the interventional methods used in cyanotic patients that can increase blood flow to the lungs and increase arterial oxygen saturation in these patients.,, The advantage of this method is that the patient does not have surgery and carries a much lower risk. Furthermore, the duration of anesthesia and the duration of hospitalization, including the intensive care unit (ICU) and the ward is much shorter and will be associated with fewer complications and mortality. This treatment can also be used in very low birth weight infants or with various syndromes that may have high mortality during surgery.,
PDA stenting may have some complications, such as migration of the stent, bleeding, vascular complications, arrhythmia, stent thrombosis, and stent fracture. Furthermore, the stability of the stent, problems during the procedure, and abnormality of vascular anatomy are among the important issues in this method.
Stenting at the right ventricular outlet is also one of the common methods to increase the oxygen saturation of these patients, which can be used along with other methods such as shunt implantation or DS., Today, DS despite being a new method has a significant place in the treatment of cyanotic CHD patients, and more operators are willing to do this procedure this method can be done using different paths such as the femoral or axillary approach.,
The evaluation of new methods and comparing them with previous methods provide new treatment strategies that are relatively safe and easy and can reduce the mortality and morbidity of different methods.,,,
This study aimed to present our experience with PDA stenting as a choice for BT-shunt in ductal-dependent cyanotic heart disease patients and compare the results and complications of DS and BT shunt implantation in this center and compare to other studies.
| Materials and Methods|| |
This was a prospective cross-sectional study performed in the Shahid Chamran hospital affiliated with Isfahan University of Medical Science, between 2012 and 2020. Demographic data such as sex, age, weight, and the presence of other congenital or genetic diseases in both groups were collected. This study was approved by the Ethics Committee of the Isfahan University of Medical Science. The parents of the patients participating in this study were given a full explanation of how to perform the intervention and its side effects, and the parents were informed to enter this study and sign for consent.
Thirty-six infants with ductal-dependent cyanotic CHDs were included with complete data. Our strategy is to offer PDA stenting in infants <2 months old and in infants older than 2 months, a BT shunt was performed.
- Infants with cyanotic CHD disease who had arterial blood oxygen saturation <75%
- Age <6 months
- Weight <6 kg.
Urgent need for surgical approach. If the file did not have the necessary data for this study.
Pre-operation diagnosis based on echocardiographic and angiographic data are listed in the table.
In the first group, infants <2 months old, the procedure was performed under general anesthesia and special attention was given to minimize hypothermia, and angiography was performed according to the standard protocol. In these patients, angiography was performed from the femoral vascular approach.
In patients whose artery duct anatomy was such that it was difficult to enter the duct through the descending aorta, the procedure was performed through the right or left subclavian artery. Most of these patients had a vertical arterial duct. The decision to perform the type of procedure was made before starting the procedure according to the echocardiographic findings. First, the injection was performed in the frontal and lateral views, and then, based on the obtained results; it was decided to continue the procedure. While positioning the stent it was ensured that the length of the stent was longer than the duct to cover the full length of the duct including both ends adequately.
The diameter of the stent was selected based on the patient's weight and PDA diameter. After fixing the guide wire in the PA, a suitable coronary stent was selected according to the length of the duct, diameter according to the weight of patients, and PDA anatomy. After confirming the position of the stent, it was deployed by inflating the balloon at a suitable pressure to fix the stent in the lumen. Finally, repeat angiography was performed and blood flow to the left and right pulmonary arteries was assessed. Ventilator and respiratory support were continued for how long needed in the postprocedure period, preferred 24 h.
In the second group, infants between 2 and 6 months old age underwent BT shunt implantation. In this group of patients, after transferring to the operating room and general anesthesia and performing preferably thoracotomy or middle sternotomy (according to the surgeon's preference), the Gortex shunt conducted blood from one of the subclavian arteries to the pulmonary branch on the same side. The size of the shunt was selected based on the weight of the infant as well as the size of the branches of the PA, which varied between 3.5 and 5 mm and with appropriate length. The placement of the shunt on the left or right side depends on the anatomy of the pulmonary branches.
Both groups received antibiotics and heparin at a dose of 50 IU/kg during the procedure based on their laboratory examination so that their activated clotting time was higher than 200 s and received higher levels of heparin if necessary. At the end of the procedure, they received 50 IU/kg of heparin every 6 h or continuously during the next 24 h related to coagulation laboratory exams. Aspirin was administered at a dose of 3–5 mg/kg/day for up to 6 months and clopidogrel at a dose of 0.3–0.5 mg/kg/day for 1–2 months. Subsequent follow-ups were performed 1, 3, and 6 months after procedures.
For the follow-up, the patients were seen regularly in the clinic with an assessment of oxygen saturation and echocardiography to assess stent patency and anatomy of pulmonary anatomy.
Statistical analysis was performed using SPSS version 22 software (IBM, Armonk, NY, USA) at the significance level of P ≤ 0.05. Quantitative and categorical data were presented as mean ± standard deviation and frequency (percentage), respectively. To compare the data, a two-tailed Student's t-test was used to express and compare variables between groups.
| Results|| |
Thirty-six neonates and infants with cyanotic CHD in two groups: BT shunt and stent placement were studied in this study. Patient demographic data are listed [Table 1]. Thirteen patients (36%) were male and 25 patients (64%) were female. [Table 2] shows the pulmonary variables of patients in the two groups. Preoperation diagnosis as shown in [Table 3].
|Table 1: Demographic variables in two groups of stent and Blalock-Taussig shunt patients|
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|Table 2: Circulatory system variables in two groups of stent and Blalock-Taussig shunt patients before shunt and stent placement and at the total correction|
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Patients' hemoglobin before the procedure was higher in the shunt group than in the stent group, but after the procedure, no statistical difference was observed in the mean hemoglobin of the patients in the two groups. Arterial blood saturation was approximately equal in both groups before procedures and after that, there was a clear increase in saturation in both groups. Right pulmonary arteries size in the stent group was mildly smaller (0.4 mm) than in the shunt group, but it was increased after the procedures. While there was no significant difference between the left PA before the procedure in the two groups, after the procedures, the growth of both pulmonary arteries occurred in both groups.
In the stent group, the duration of ICU hospitalization was significantly different and shorter compared to the shunt group. The length of hospital stay in the stent group at the time of the procedure was significantly different from the shunt group and was shorter.
In one patient in the stent group, which was the arterial duct between the left subclavian artery and the left PA (congenital BT shunt), the stent was placed in the half-distal part of the duct and the patient experienced a decrease in saturation after 48 h. Due to the absence of an interventionist at that time in the province, a right BT shunt was performed for the patient but unfortunately, her saturation decreased on the 2nd day after the operation and she was transferred to the catheterization lab once again due to stenosis at the site of the anastomosis. The shunt flow was not sufficient to the lungs, especially the left lung. Another stent was placed telescopically in the proximal part of the previous stent and the saturation increased [Figure 1].
|Figure 1: Duct-dependent stenting. (a) Primary injection and site of arterial duct separation from left subclavian artery. (b) Ductal stenting in the distal of patent ductus arteriosus. (c) Injection in the right shunt and lack of proper blood flow to the lung due to stenosis of the shunt site. (d) Severe stenosis at the proximal part of the previous stent. (e) Second stent implantation telescopically in proximal part before the previous stent|
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In one patient, during the procedure, the stent migrated to the distal part of the left PA, and another stent was placed in the duct. The presence of a stent in the distal part of the left PA did not cause late complications for the patient. One of the patients, unfortunately, died due to severe tortuosity of PDA and when the stent was placed in the distal part of the PDA it compressed another part of duct and stopped the flow. No other significant complications such as stent displacement, stent thrombosis or stent fracture, bleeding, or arrhythmia were observed in the other patients.
In the shunt group, ten patients had a left shunt and eight patients had a right shunt.
There was one–hospital death in stented group.
One patient also developed stenosis at the shunt junction, which was re-implanted with a stent.
In three patients, the shunt junction with the pulmonary branches was narrowed without the need for more reoperation. Other complications such as heart block, bleeding, and sudden death was not seen.
| Discussion|| |
In this study, we investigated the palliative treatment of patients with ductal-dependent cyanotic CHD who have undergone two different approaches using BT shunt, which is a traditional method for increasing arterial blood oxygenation, and have compared it to DS implantation, which is a newer approach. Implantation of BT shunt had various complications such as thrombosis and sometimes caused asymmetrical growth of branches or blockage of branches that required different treatments., In our study, three patients (16%) had stenosis and distortion at the anastomosis to the branches, which was repaired during subsequent surgeries.
In a multicenter study by Bentham et al. between 2012 and 2015 that compared shunted patients and DS in the UK, 171 patients were shunted, and 83 patients were stented. In the above study, duct stents had a better advantage over shunts and had fewer complications and better survival in neonatal patients. Although our study was in one center and on a smaller number of patients, the results of our study were consistent with this study. Our DS group had shorter hospital stays and fewer complications than shunted patients.
In Alsagheir et al.'s study, which was a systematic review, the researcher reported that there was no significant difference in the stent and shunt mortality during the 1st month after the procedure. In the stent method, the complications of the procedure were much less than the shunt, but the need for reoperation was higher in these patients. As mentioned in the results, the postoperative complications were similar in our patients.
One of the patients in both groups died in the 1st month of the procedure, while in the stent group in the catheterization laboratory unit and the shunt group in the ICU. One of our stent groups needed reoperation and a BT shunt was placed and then a second stent was placed in the duct due to insufficient flow. In terms of other short-term and medium-term complications, both groups were similar.
Contrary to previous studies in McMullan et al. report, the need for another procedure in patients in this study was the same and 3 patients in each group were needed. However, in shunt patients, complications such as stenosis are more common. In our study, reoperation was seen in a stent patient and shunt patients did not need reoperation.
The operator's experience with the complications during and after surgery seems to be very important. As seen in various studies, postoperative complications are somewhat equal in both shunt and stent groups if these patients are treated by skilled operators. Although DS can also be done in patients of younger ages and weights. However, it should be noted that stenting in these patients significantly reduces the time of hospitalization in the ICU and hospital, and also if the shunt is implanted by sternotomy, subsequent adhesions make reoperation difficult for the surgeon.
The need for re-intervention is more seen in patients in the stent group, which will probably be less in the future with more experience of operators. A noteworthy point in our patient who needed re-intervention was to stent must be covered the entire length of the duct in all patients in the first procedure, otherwise, spasms of the remaining part of the duct can lead to complications and the need for another procedure. We think that in the future, with the expansion of interventional approaches, we will move to a point where the number of shunts will be done much less, and surgeons have more time to perform complex surgeries.
Wessel et al.'s study show that adding clopidogrel to conventional therapy did not reduce mortality from any cause or shunt-related morbidity in neonates or infants with CHD palliated with a systemic to pulmonary shunt.
In Talwar et al.'s study, the median sternotomy approach for modified BTS is preferred to the thoracotomy approach (or sternotomy in the decision of the surgeon) with fewer shunt failures. In our study, BTS was classically performed via the thoracotomy and sternotomy approach (according to the surgeon's preference), because of minimal access incision that gives good surgical exposure and adhesion-free mediastinum, although accurate evaluation of PA branches before the operation is needed.
| Conclusion|| |
Stent placement in duct-dependent cyanotic patients has equal value to BT shunt in terms of increased arterial oxygen in these patients. Furthermore, these patients have less mortality and morbidity and it can be done in newborn and infants with less weight and age and it is a safe and effective method.
In this study, the number of our patients was small due to the small number of these patients in each center, and if this study was done as a multicenter, the results would be much better and more reliable. Furthermore, due to the small number of patients, it was not possible to divide these patients into different groups of patients so that the results could be evaluated in each disease separately. Perhaps in future studies, this issue can be solved by increasing the number of patients.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]