Comparisons Between Ductal Stenting and Blalock-Taussig Shunts for Infants With Ductal-Dependent Pulmonary Circulation
2018; Lippincott Williams & Wilkins; Volume: 137; Issue: 6 Linguagem: Inglês
10.1161/circulationaha.117.031998
ISSN1524-4539
Autores Tópico(s)Cardiovascular Conditions and Treatments
ResumoHomeCirculationVol. 137, No. 6Comparisons Between Ductal Stenting and Blalock-Taussig Shunts for Infants With Ductal-Dependent Pulmonary Circulation Free AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessEditorialPDF/EPUBComparisons Between Ductal Stenting and Blalock-Taussig Shunts for Infants With Ductal-Dependent Pulmonary Circulation Lee Benson, MD and Glen Van Arsdell, MD Lee BensonLee Benson Departments of Pediatrics and Surgery, Divisions of Cardiology (L.B.) and Glen Van ArsdellGlen Van Arsdell Cardiovascular Surgery (G.V.A.), The Labatt Family Heart Center, The Hospital for Sick Children, University of Toronto School of Medicine, Canada Originally published6 Feb 2018https://doi.org/10.1161/CIRCULATIONAHA.117.031998Circulation. 2018;137:602–604Articles, see p 581 and p 589Nothing is as powerful as an idea whose time has come.—Victor Hugo, Histoire d'un Crime (1852)On November 29, 1944, Dr Alfred Blalock performed the first anastomosis of the subclavian to the pulmonary artery in a child with cyanosis at the Johns Hopkins Hospital in Baltimore. This novel operation was supported by the laboratory work of Vivien Thomas and the encouragement of pediatric cardiologist Helen Taussig. The operation, thereafter called the Blalock-Taussig shunt (BTS), increased pulmonary blood flow (PBF) and relieved symptomatic cyanosis.1 This singular procedure ushered in the modern era of management of the child with complex congenital heart disease and became the foundation for all management strategies that followed. Although the procedure or 1 of its modifications (MBTS) has remained a stalwart for securing a source of pulmonary blood flow for >70 years, an appreciable mortality and morbidity remains.2 As such, alternative management strategies have been suggested and tested in lieu of primary repair.3In 1991, Coe and Olley4 described a novel transcatheter approach to increase PBF by stenting the arterial duct. Although attractive, initial clinical applications were disappointing.5 However, with improved delivery and stent platforms paralleling an experience with ductal stenting in infants with dual-source PBF, the last decade has seen a number of clinical units apply the technique in single-source PBF lesions.6,7 Avoidance of early cardiothoracic surgery, promoting pulmonary artery growth, and a potentially stable source of PBF are potential advantages.7 Studies comparing ductal stenting (DS) to a MBTS, however, have been limited to small patient numbers or inclusion of nonductal-dependent lesions.8,9In this issue of Circulation, 2 studies10,11 are presented that compare DS to surgical shunts in the current era in the setting of ductal-dependent PBF. Bentham and colleagues10 from 9 pediatric cardiology centers in the United Kingdom reviewed data from the National Congenital Heart Audit comparing the outcomes of 171 neonates who underwent a MBTS and 83 who underwent attempted DS in the setting of ductal-dependent PBF between 2012 and 2015. Interestingly, just over a third of the DS and MBTS groups had some degree of antegrade PBF, although it was felt to be inadequate. In the DS group, a crossover to a surgical shunt occurred in 17% (procedure success rate 82.9%), with the majority of events occurring acutely due to procedural failure and late events because of stent failure. Multivariable analysis (with an accommodating propensity score) found that the DS group had better odds of survival, lessened risk of death before repair (P=0.012, P=0.026), and reduced odds of requiring extracorporeal membrane oxygenation (P=0.058) after the procedure compared with the MBTS group. Stented infants, however, were found to have slightly increased odds of reintervention (39.8% versus 24%; P=0.165). Compared with the MBTS group, the DS group had shorter ventilator days, intensive care unit stays, and total hospital days. Time to the next stage in care (either further surgical palliation or complete repair) and presurgical arterial saturations were similar, as was body weight and pulmonary artery growth (assessed in only half the cohort), whereas in the DS group, an increased need for pulmonary arterioplasty was found.The companion article11 in this issue of Circulation originates from 4 North American pediatric cardiology centers representing the Congenital Catheterization Research Collaborative. These authors performed a retrospective cohort study reviewing all infants with ductal-dependent PBF <1 year of age having either a DS or MBTS between 2008 and 2015. Unlike the companion UK paper, almost two thirds of the DS group and just over a third of the MBTS group had another source of PBF, albeit similarly considered inadequate. The cohort consisted of 106 infants in the DS group and 251 treated with a MBTS. It is interesting to note that more infants with pulmonary atresia/intact ventricular septum or critical pulmonary stenosis and those with a biventricular heart with antegrade PBF were chosen for a DS strategy. Death or unplanned reintervention (either catheter-based or surgical) to treat cyanosis was the primary outcome parameter. A propensity score was utilized to adjust for baseline group differences. The adjusted composite outcome was found to be not different between groups (P=0.31), although as in the UK study, unplanned reinterventions were more common in the DS group for both cyanosis- and noncyanosis-related procedures. The DS group had a lower intensive care unit stay, fewer procedural complications, and a lower diuretic requirement at hospital discharge (P<0.001). In contrast to the UK experience, pulmonary artery growth was found to be significantly better in the DS group, and that growth was more symmetrical at the time of repair, whereas the need for a pulmonary arterioplasty was not different between groups.Although primary repair for infants with complex cyanotic heart lesions is attractive, it comes at a price.12–14 Infants of low birth weight, prematurity, and hypoplastic pulmonary arteries are at increased perioperative risk, and as such they require a palliative treatment strategy to enhance pulmonary artery size and allow somatic growth. Although the MBTS provides a secure source of PBF, it is achieved with well-defined procedural morbidity and mortality. In this issue of Circulation, 2 well-designed studies10,11 present outcomes comparing 2 divergent treatment approaches. Despite variability in practice, operator experience, and potential selection bias, the findings are strikingly similar. Both identify that DS is noninferior in clinical outcomes to MBTS and superior in several clinical variables. The requirement for reintervention to address flow limitations through the stent is the price to be paid, underscoring the need for well-defined follow-up to monitor the infants to avoid unplanned intervention to address limited ductal flow. The possibility of a positive impact on pulmonary artery growth, as noted in the North American study, may influence long-term outcomes.What was not addressed in these reports was the variability in ductal anatomy, and how morphology may challenge technical success and clinical effectiveness (eg, the presence of ductal-left pulmonary artery coarctation and potential isolation). Was there a preferred anticoagulant/antiplatelet regimen in the DS cohort? Could the effectiveness of DS be improved by the use of drug-eluting stents?15 Was there a preferred approach for vascular access, with utility and safety increased through unconventional access such as the carotid artery? Furthermore, neither study separates out infants with true single-source PBF.Should we abandon the MBTS for DS? These studies do not answer that question. These reports, however, lend support to the continued use of this treatment strategy as an alternative palliation to surgical shunts and further ongoing study, a position we at SickKids support and are pursuing.DisclosuresNone.FootnotesThe opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.Circulation is available at http://circ.ahajournals.org.Correspondence to: Lee Benson, MD, The Hospital for Sick Children, 555 University Avenue, Toronto, Canada M5G1X8. E-mail [email protected]References1. Blalock A, Taussig HB. 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What is the optimal age for repair of tetralogy of Fallot?Circulation. 2000; 102(19Suppl 3):III123–III129.MedlineGoogle Scholar13. Wilder TJ, Van Arsdell GS, Benson L, Pham-Hung E, Gritti M, Page A, Caldarone CA, Hickey EJ. Young infants with severe tetralogy of Fallot: Early primary surgery versus transcatheter palliation.J Thorac Cardiovasc Surg. 2017; 154:1692.e2–1700.e2. doi: 10.1016/j.jtcvs.2017.05.042.CrossrefGoogle Scholar14. Williams JA, Bansal AK, Kim BJ, Nwakanma LU, Patel ND, Seth AK, Alejo DE, Gott VL, Vricella LA, Baumgartner WA, Cameron DE. Two thousand Blalock-Taussig shunts: a six-decade experience.Ann Thorac Surg. 2007; 84:2070–2075. doi: 10.1016/j.athoracsur.2007.06.067.CrossrefMedlineGoogle Scholar15. Lee KJ, Seto W, Benson L, Chaturvedi RR. Pharmacokinetics of sirolimus-eluting stents implanted in the neonatal arterial duct.Circulation Cardiovasc Interv. 2015; 8:e002233. doi: 10.1161/CIRCINTERVENTIONS.114.002233.LinkGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Alsagheir A, Koziarz A, Makhdoum A, Contreras J, Alraddadi H, Abdalla T, Benson L, Chaturvedi R and Honjo O (2021) Duct stenting versus modified Blalock–Taussig shunt in neonates and infants with duct-dependent pulmonary blood flow: A systematic review and meta-analysis, The Journal of Thoracic and Cardiovascular Surgery, 10.1016/j.jtcvs.2020.06.008, 161:2, (379-390.e8), Online publication date: 1-Feb-2021. Sagar P, Sivakumar K, Umamaheshwar K, Sonawane B, Mohakud A, Rajendran M, Agarwal R, Varghese R and Sheriff E (2020) Are early palliative procedures providing an adequate long-term benefit in young cyanotic infants from developing countries, despite advances in surgery and interventions?, Cardiology in the Young, 10.1017/S1047951120003947, 31:3, (358-370), Online publication date: 1-Mar-2021. Sivakumar K, Pavithran S, Sonawane B, Rajendran M and Ramasamy R (2020) Serum Sirolimus Levels After Implantation of Third Generation Drug Eluting Cobalt Chromium Coronary Stent in Ductus Arteriosus in Neonates with Duct-Dependent Pulmonary Circulation, Pediatric Cardiology, 10.1007/s00246-020-02381-4, 41:7, (1354-1362), Online publication date: 1-Oct-2020. Roggen M, Cools B, Brown S, Boshoff D, Heying R, Eyskens B and Gewillig M (2020) Can ductus arteriosus morphology influence technique/outcome of stent treatment?, Catheterization and Cardiovascular Interventions, 10.1002/ccd.28725, 95:6, (1149-1157), Online publication date: 1-May-2020. Merlocco A (2018) Fetal hemodymanic effects on ductus arteriosus development and influences on postnatal management in infants with ductal-dependent pulmonary blood flow, Congenital Heart Disease, 10.1111/chd.12719, 14:1, (100-104), Online publication date: 1-Jan-2019. Daaboul D, DiNardo J, Nasr V and Ramamoorthy C (2019) Anesthesia for high‐risk procedures in the catheterization laboratory, Pediatric Anesthesia, 10.1111/pan.13571, 29:5, (491-498), Online publication date: 1-May-2019. February 6, 2018Vol 137, Issue 6 Advertisement Article InformationMetrics © 2018 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.117.031998PMID: 29431661 Originally publishedFebruary 6, 2018 Keywordsductal stentingBlalock-Taussig shuntEditorialscongenital heart diseasePDF download Advertisement
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