Stenting the Ductus Arteriosus

Abstract

In 1947, Dr Helen B. Taussig wrote of the aortopulmonary surgical shunt operation that she and Dr Alfred Blalock developed to increase pulmonary artery blood flow, "The essence of the operation is the creation of an artificial ductus arteriosus through which a mixture of arterial and venous blood is directed to the lungs." 1 Who could have imagined that 50 years later, some of us would be trying to create an "artificial" Blalock-Taussig shunt through manipulation of the ductus arteriosus. See p 2621Our institution has been a pioneer in neonatal cardiac transplantation since 1985 2 ; hence, the opportunities to explore new ways of extending the survival of the potential recipients awaiting the right donor are many. Our productive combination of a confident pediatric cardiac surgical team with a creative pediatric interventional cardiology department, operating under a Food and Drug Administrationapproved protocol, began stenting the ductus arteriosus in patients with hypoplastic left heart syndrome (HLHS) who had evidence of ductal flow restriction while the patients were awaiting heart transplantation. 3 It would have been too ambitious to extend the protocol to pathologic conditions other than the medically unresponsive HLHS listed for transplantation because the surgical outcomes for aortopulmonary shunts at our and most other centers have been outstanding. 4 In addition, we were uncertain about stent use in general, notwithstanding their use in the ductus arteriosus; for ductus arteriosus use, only animal experience had been reported 5-7 and, unfortunately, no good animal models for these complex congenital heart malformations exist.The use of stents to maintain the patency of the ductus arteriosus in neonates with ductal-dependent systemic blood flow and infants with ductal-dependent pulmonary blood flow congenital anomalies, one of the subjects of the present report in Circulation, 8 is of particular interest. The authors of the present report have shown the courage and skills required of interventionists to develop the notion of a nonsurgical, artificial, Blalock-Taussig shunt.We concur with the authors that their long-term results were suboptimal, despite initial technical success. However, we should be cautious about drawing firm conclusions before analyzing these results in context.Stenting the ductus arteriosus in patients with ductdependent systemic blood flow, such as those with HLHS, assumes that the patient was not responding to conventional prostaglandin E-1 therapy and that the hemodynamic problem arose from a restrictive duct, not from a restrictive atrial septal defect (ASD). Furthermore, this type of stenting implies that the center where the stent procedure is being contemplated has a successful neonatal transplant program where potential recipients must await a matching donor's heart. Patients being considered for univentricular palliation with Norwood's staged procedures do not need a ductal stent because the sooner those patients undergo surgical reconstruction, the better their outcomes. ...

Interventional cardiac catheterisation in congenital heart disease

“…This led to an unacceptably high mortality rate, due to ductal spasm during the procedure or stenosis subsequently. 11 The vast majority of babies in this situation undergo a surgical aortopulmonary shunt, such as the modified Blalock-Taussig shunt.…”