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ORIGINAL ARTICLE
Year : 2021  |  Volume : 34  |  Issue : 3  |  Page : 1179-1183

Duct-dependent cyanotic neonates with patent ductus arteriosus stenting pose a unique challenge for the next stage of surgical intervention


1 Department of Cardiothoracic Surgery, Faculty of Medicine, Menoufia University, Menoufia, Egypt; Pediatric Cardiac Surgery Department, Madina Cardiac Center (MCC), Madina, Saudi Arabia
2 Pediatric Cardiac Surgery Department, Madina Cardiac Center (MCC), Madina, Saudi Arabia
3 Pediatric Cardiac Surgery Department, Madina Cardiac Center (MCC); Faculty of Medicine, Taebah University, Madina, Saudi Arabia

Date of Submission14-Jan-2021
Date of Decision08-Mar-2021
Date of Acceptance25-Mar-2021
Date of Web Publication18-Oct-2021

Correspondence Address:
Ayman R Abdelrehim
Department of Cardiothoracic Surgery, Faculty of Medicine, Menoufia University, Menoufia

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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_12_21

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  Abstract 


Objective
To study the role of patent ductus arteriosus (PDA) stenting in the management of single-ventricle patients and the surgical difficulties facing the surgeons in the next stages of surgical procedures.
Background
Thirty consecutive neonates with cyanotic duct-dependent lesions were initially palliated with (PDA) stenting in our center. Eighteen of them had undergone one or more surgical procedures. We retrospectively assessed the indexed growth of pulmonary arteries (PA) over a period of time and the requirement of further rehabilitation of PAs in these patients.
Patients and methods
From January 2014 to December 2018, 30 neonates with cyanotic congenital heart diseases underwent PDA stenting as initial palliation; 60% were ventilated before the procedure, which resulted in 100% success. All patients were followed up regularly by monitoring of PA size imaging. Eighteen patients of this group underwent further surgical procedures.
Results
Ninety percent of the neonates had stenosis of the PA branches before PDA stenting. The indexed PA branch size was significantly smaller, which increased after stenting of PDA. At the time of the next surgical procedures (Glenn, etc.), stent division/ligation was required in addition to PA plasty in 90% of patients.
Conclusions
PDA stenting provides efficient palliation in cyanotic neonates. Despite the origin of stenosis, the stent allowed growth in the size of both PAs. However, the majority required surgical augmentation and further stenting of PAs in the mid-term follow-up.

Keywords: patent ductus arteriosus stenting, pulmonary arteries, stenosis


How to cite this article:
Abdelrehim AR, Aitizaz S, Khoshhal SQ, Almutairi MB, Al-Muhaya MA. Duct-dependent cyanotic neonates with patent ductus arteriosus stenting pose a unique challenge for the next stage of surgical intervention. Menoufia Med J 2021;34:1179-83

How to cite this URL:
Abdelrehim AR, Aitizaz S, Khoshhal SQ, Almutairi MB, Al-Muhaya MA. Duct-dependent cyanotic neonates with patent ductus arteriosus stenting pose a unique challenge for the next stage of surgical intervention. Menoufia Med J [serial online] 2021 [cited 2024 Mar 29];34:1179-83. Available from: http://www.mmj.eg.net/text.asp?2021/34/3/1179/328290




  Introduction Top


Patients with congenital heart disease with duct-dependent pulmonary circulation need prompt measures to establish stable pulmonary blood flow within the first few days of life before the physiological closure of patent ductus arteriosus (PDA). Prostaglandin infusion is usually effective in maintaining the patency of PDA until interventional or surgical procedures are performed [1].

PDA stenting has been proposed since the early 1990s for maintaining ductal patency as an alternative to Blalock–Taussig shunts [2]. The modified Blalock–Taussig shunts in neonates continues to be associated with significant morbidity and mortality, which has made PDA stenting an acceptable alternative in such cases [3].

Early results of PDA stenting have not been encouraging because of frequent complications, including pulmonary artery (PA) or PDA perforation, stent dislodgment, and suboptimal positioning [4]. Improvements in the design and manufacture of coronary stent devices and delivery systems, such as flexibility, trackability, and heparin coating, have vastly contributed to their safe application in PDA [5]. Recent publications of large multicenter studies are likely to strengthen this conclusion [6].

Babies who have undergone a previous PDA stenting in duct-dependent pulmonary circulation now represent a new subset of challenges at the time of reparative operations [7],[8],[9].

The proposed qualitative and quantitative PDA morphology classification scheme may be helpful in anticipating outcomes in patients with duct-dependent pulmonary blood flow undergoing PDA stenting [10].

The aim of this study is to highlight the role of PDA stents as a primary palliative procedure for duct-dependent pulmonary circulation, present the initial results after PDA stenting, with the main focus on the surgical challenges and the growth of PA branches, and discuss the challenges of PA reconstruction during future procedures in these patients.


  Patients and methods Top


This randomized-controlled study, after review of medical records and computerized hospital data, was approved by the ethical committee of the Madinah Cardiac Center MCC, a written informed consent was obtained from all patients within this study. We retrospectively reviewed data of patients (30 patients) who underwent cardiac operations after percutaneous PDA stent implantation between January 2014 and December 2018. Thirty consecutive neonates with congenital heart malformations and duct-dependent pulmonary blood flow circulation who underwent percutaneous PDA stent placement in the catheterization laboratory were included.

Preoperative and postoperative two-dimensional echocardiograms, angiographic fluoroscopy, and lung scans were reviewed. Variables analyzed included age at the time of PDA stenting and at the time of the operations, time between PDA stent placement and the operation, need for interventional cardiologic procedures before and after the operation, presence of PA distortion or stenosis, need for additional operations on PA branches, postoperative complications, anatomy status of PA branches at the last follow-up, and need for further postoperative interventional cardiology procedures in patients with residual PA stenosis.

PDA stenting yielded 100% procedural success and 96% survival to discharge. Of the patients, 60% were ventilated and 92% were on prostaglandin infusion at the time of PDA stenting. 75% of the patients had branch PA branch stenosis at the time of stenting, predominantly (90%) left pulmonary artery (LPA) stenosis [Table 1].
Table 1: Demographic data of the patients at the time of patent ductus arteriosus stenting

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Eighteen of the patients who had undergone PDA stenting (60%) underwent further surgical palliative operations.

The primary outcome was the surgical treatment, and the results focused mainly on the status of the PA branches at the time of repair and at follow-up as the need for additional surgical maneuvers or an interventional cardiology procedure on central PAs. Hospital mortality and morbidity were also considered.


  Results Top


All our patients were under regular follow-up; 12 patients had single-ventricle physiology and six patients had biventricular physiology with different anatomies as shown in [Table 2].
Table 2: Diagnoses of patients who underwent successful stent implantation

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The mean age of the neonates was about 9 months at the time of readmission for the next intervention, with a median weight of 7.2 kg (weight gain was good compared with the weight at the time of PDA stenting). The mean transcutaneous oxygen saturation (preoperative) was 82% (mean ± SD = 82 ± 7.3) [Table 3].
Table 3: Preoperative date (age, O2%, weight, and ventricle morphology)

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From the standard catheter measurements and intraoperative Hegar size, we found that in most of the patients [except in three right pulmonary artery (RPA), and six LPA], the diameter of the PAs showed improved growth to different degrees ([Figure 1]a for RPA) ([Figure 2]a for LPA). However, after revision of nomograms of the PAs, seven patients (one RPA – six LPA) had a significant under growth Z score (−2) ([Figure 1]b for RPA and [Figure 2]b for LPA).
Figure 1: Right pulmonary artery (RPA), diameter (mm) (a). RPA indexed Z score diameter (b).

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Figure 2: Left pulmonary artery (LPA), diameter (mm) (a). LPA indexed Z score diameter (b).

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The intraoperative problems were not only related to the size of the PAs alone but also the presence of PDA stents due to fibrous reaction with intraductal and extraductal fibrous tissue growth. Therefore, the PDA stent was completely surrounded by fibrous tissue, but we successfully completely placement of enucleated stents for two patients from the ductal wall. In the remaining four patients, PDA stents were clipped and doubly ligated with silk ties and divided, and ductal tissue was removed from pulmonary sides; then, augmentation of the PAs was performed with a bovine pericardial patch in all patients (six patients with under growth of PAs).

In [Table 4], it can be seen that five patients had prolonged ICU stay (more than 3 days). There was no operative mortality. In two patients, recurrent pleural effusion and the need to insert chest tubes led us to reassess the Glenn circulation in the cardiac catheterization laboratory. In both cases, the LPA narrowing with a gradient of more than 6 mmHg was relieved by LPA stenting. This led to prompt resolution of pleural effusions [Figure 3]. One patient after the Fontan procedure (with 5 mmHg gradient) in LPA postoperatively with recurrent pleural effusion had similar outcomes after LPA stenting and relief of stenosis.
Figure 3: Intervention catheter before and after patent ductus arteriosus stenting (pulmonary atresia with a ventricular septal defect) (a) and left pulmonary artery stenting after the Glenn procedure (b).

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Table 4: Postoperative complications

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  Discussion Top


Ductal stenting is a practical, effective, safer, and less invasive method compared with palliative surgery. Patients with ductal stenting have some degree of growth of the PA, which provides additional time for surgical repair. Odemis et al. [11] suggested that ductal stenting should be considered as a first treatment step in newborns with duct-dependent pulmonary circulation. However, long-term palliation without stent restenosis might still be a concern, especially in patients with hypoplastic PAs.

Gibbs et al. [2] reported, in a macroscopic study, that a complete layer of endothelium forms over the stent as early as 1 month. With time, the neo-endothelium proliferation becomes thicker, leading to a progressive PDA lumen obstruction, requiring additional percutaneous stent dilatations before the surgical correction [12].

Also, Alwi and colleagues reported that the presence of a PDA stent accelerates pre-existing stenosis of the PAs, mainly on the LPA. They concluded that the metal grid stent induces intense neo-intimal proliferation and fibrosis in the ductal tissue [11].

Because PDA implants at the origin of LPA, the higher incidence of stenosis in that branch can be explained by the concomitant effect of the 'pulmonary coarctation' and the neo-intimal hyperplasia as Gibbs et al. [2] suggested.

On the other hand, Santoro et al. [13] reported that PDA stenting was associated with significant and balanced PA growth in congenital heart diseases with completely duct-dependent pulmonary circulation over a short-term follow-up. Thus, it may be considered as an alternative to surgical palliation in this subset of patients.

From our experience, there was a need for augmentation of PAs after PDA stenting in 6/18 (33%) patients using a pericardial patch; in 2/6 (33%) patients, restenosis occurred and they required further percutaneous dilation with stent implantation in the PAs.

Also, removal of stents was extremely difficult due to incorporation of the stents within the ductal wall and their extension at the sides of the aortic and PAs.

We should mention that the presence of the hard material of the stent led to more fixation (because of fibrosis and the hard material of the stent) and difficult tissue dissection because, in most cases, it was found behind the aorta, adherent to its posterior wall.

Our suggestions seem to be supported by other studies [2],[9],[10]. The stent fibrotic reaction created an impaired endothelial function that was accelerated by the material of the stent.

In brief, surgical interventions after PDA stenting are becoming routine procedures with low risk and good mid-term results. The advent of PDA stenting has created a new group of patients; pediatric cardiac surgeons need to have experience in the management of stented PAs in such patients.

We have shown that PA plasty can produce good results in enlarging stenotic PAs, but cannot definitely resolve PA stenosis in all patients because of the increased stiffness of the PA walls. PDA stenting requires further surgical or catheter-based interventions in nearly one-third of the cases. Nearly always, it is the LPA that shows fibrotic narrowing at its origin after PDA stenting (pulmonary coarctation). Vigilance in monitoring PA sizes and their indexed growth is required in the long-term management of these patients. Timely intervention with catheter-based dilation or stenting can prevent complications associated with a single-ventricle circulation.

There are some limitations in our study. This was a nonrandomized retrospective study with a small number of patients, we included both single and biventricular repair cases, and there was no information available about the morphology of ductus arteriosus before stenting.


  Conclusions Top


PDA stenting provides efficient palliation in cyanotic neonates. Despite the origin of stenosis, the stent allowed growth in the size of both PAs. However, the majority required surgical augmentation and further stenting of PAs in the mid-term follow-up.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Blalock A, Taussig H. The surgical treatment of malformations of the heart in which there is pulmonary stenosis or pulmonary atresia. JAMA 1945; 128:189–202.  Back to cited text no. 1
    
2.
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Feltes TF, Bacha E, Beekman RH, Cheatham JP, Feinstein JA, Gomes AS, et al. Indications for cardiac catheterization and intervention in pediatric cardiac disease: a scientific statement from the American Heart Association. Circulation 2011; 123:2607–2652.  Back to cited text no. 4
    
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Glatz AC, Petit CJ, Goldstein BH, Kelleman MS, McCracken CE, McDonnell A, et al. Comparison between patent ductus arteriosus stent and modified Blalock-Taussig shunt as palliation for infants with ductaldependent pulmonary blood flow. Insights from the congenital catheterization research collaborative. Circulation 2018; 137:589–601.  Back to cited text no. 6
    
7.
Vida VL, Speggiorin S, Maschietto N, Padalino MA, Tessari C, Biffanti R, et al. Cardiac operation after patent ductus arteriosus stenting in ductdependent pulmonary circulation. Ann Thorac Surg 2010; 90:605–609.  Back to cited text no. 7
    
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Bentham JR, Zava NK, Harrison WJ Shauq A, Kalantre A, Derrick G. Duct stenting versus modified Blalock-Taussig shunt in neonates with duct-dependent pulmonary blood flow. Associations with clinical outcomes in a multicenter national study. Circulation 2018; 137:581–588.  Back to cited text no. 8
    
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Boucek DM, Qureshi AM, Goldstein BH, Petit CJ, Glatz AC. Blalock-Taussig shunt versus patent ductus arteriosus stent as first palliation for ductal-dependent pulmonary circulation lesions: a review of the literature. Congenit Heart Dis 2019; 14:105–109.  Back to cited text no. 9
    
10.
Qureshi AM, Goldstein BH, Glatz AC, Agrawal H, Aggarwal V, Ligon RA, et al. Classification on scheme for ductal morphology in cyanotic patients with duct dependent pulmonary blood flow and association with outcomes of patent ductus arteriosus stenting. Catheter Cardiovasc Interv 2019; 93:933–943.  Back to cited text no. 10
    
11.
Odemis E, Haydin S, Guzeltas A, Ozyilmaz I, Bilici M, Bakir I. Stent implantation in the arterial duct of the newborn with duct-dependent pulmonary circulation: single centre experience from Turkey. Eur J Cardiothorac Surg 2012; 42:57–60.  Back to cited text no. 11
    
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Alwi M, Choo KK, Latiff HA, Kandavello G, Samion H, Mulyadi MD. Initial results and medium-term follow-up of stent implantation of patent ductus arteriosus in ductdependent pulmonary circulation. J Am Coll Cardiol 2004; 44:438–445.  Back to cited text no. 12
    
13.
Santoro G, Capozzi G, Caianiello G, Palladino MT, Marrone C, Farina G, Russo MG, Calabro R. Pulmonary artery growth after palliation of congenital heart disease with duct-dependent pulmonary circulation: arterial duct stenting versus surgical shunt. J Am Coll Cardiol 2009; 54:2180–2186.  Back to cited text no. 13
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
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  [Table 1], [Table 2], [Table 3], [Table 4]



 

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