Ductal anatomy: a determinant of successful stenting in hypoplastic left heart syndrome
M M Boucek1, C Mashburn, E Kunz
1University of Colorado, The Children's Hospital, Denver, CO 80218, USA.
Insights
Ductal stenting is a successful interventional palliation for hypoplastic left heart syndrome (HLHS), with 97% success in 40 infants. Favorable ductal anatomy is key to minimizing complications and mortality in HLHS patients.
Area of Science:
- Pediatric Cardiology
- Interventional Cardiology
- Congenital Heart Disease
Background:
- Hypoplastic left heart syndrome (HLHS) presents significant morbidity and mortality challenges.
- Current palliative strategies for HLHS aim to improve outcomes.
- Interventional palliation, specifically ductal stenting, is explored as a less invasive approach.
Purpose of the Study:
- To evaluate the efficacy and safety of arterial duct stenting in infants with HLHS.
- To analyze the relationship between ductal anatomy orientation and procedural outcomes.
- To determine the feasibility of primary ductal stenting for HLHS palliation.
Main Methods:
- Retrospective review of 40 consecutive HLHS patients undergoing ductus arteriosus (DA) stenting.
- Classification of DA anatomy based on frontal plane orientation (Type 1, 2, 3).
- Analysis of technical success, procedural complications, mortality, and clinical outcomes.
Main Results:
- Successful stenting was achieved in 97% (39/40) of infants.
- Type 1 DA anatomy (leftward loop) had 100% technical success with low complications (8%).
- Type 2 DA anatomy (mesoverted) had 100% success but higher complication rates (~50%). Type 3 (rightward axis) had limited success in a small cohort.
- No procedural mortality; all stented patients weaned from prostaglandins; two late coarctation complications.
Conclusions:
- Ductal stenting with self-expanding nitinol stents is a highly successful intervention for HLHS.
- Ductal anatomy significantly influences technical success and complication rates.
- Primary ductal stenting should be considered for HLHS patients with favorable ductal anatomy.
Abstract:
Interventional palliation for hypoplastic left heart syndrome (HLHS) could reduce the current morbidity and mortality. Stenting of the arterial duct is the critical interventional step for HLHS. We reviewed our experience with 40 consecutive patients with HLHS referred for stenting of the ductus arterious (DA). Thirty-nine of 40 (97%) infants had suitable anatomy and were successfully stented. The infants were grouped by orientation of the ductus in the frontal plane. Type 1 DA anatomy had a leftward loop at a mean orientation of 18 degrees from the vertical plane. Type 2 ductal anatomy was mesoverted, with a mean orientation of 7.1 degrees from the vertical plane. Type 3 ductal anatomy displayed a rightward axis, with a mean of -4 degrees rightward. Orientation of the DA was significantly related to length of the ductus, number of stents required for complete coverage, and technical and procedural complications. Type 1 DA occurred in 65% of patients, and there was 100% technical success, no mortality, and only an 8% incidence of complications. Type 2 anatomy occurred in 27% of patients and there was 100% success. However, the technical and procedural complications increased to approximately 50%. Type 3 ductal anatomy was seen in only 3 patients, 2 of whom were successfully stented. There was no procedural-related mortality, and all stented patients were weaned from prostaglandin. There were only two late complications (coarctation). We conclude that ductal stenting using self-expanding nitinol stents is successful in more than 95% of infants with HLHS. Patients with HLHS and favorable ductal anatomy should be considered for primary ductal stenting.
