Choice of shunt type for the Norwood I procedure: does it make a difference?

This study aimed to compare pulmonary artery (PA) growth between patients who received a right ventricle-to-PA (RV-PA) shunt and those who received a modified Blalock-Taussig shunt (mBTS).

All consecutive patients with hypoplastic left heart syndrome who underwent the Norwood I procedure between 2001 and 2017 were included in the study. Pre-stage 2 angiograms were analysed to measure the size of the PA. The Nakata index was calculated to estimate PA growth. The ratio of the right PA to left PA cross-sectional area (RPA/LPA) was used to calculate the difference in growth between the 2 branches. Study end points were shunt failure, shunt-related mortality and growth of the PAs.

A total of 223 patients with hypoplastic left heart syndrome (RV-PA group = 137, mBTS group = 86) underwent the Norwood I procedure, and 186 patients (RV-PA n = 116, mBTS n = 70) achieved the stage 2 procedure. PA growth was better in patients with mBTS (Nakata index: RV-PA = 282, mBTS = 315 mm2/m2, P = 0.021). LPA growth was worse compared to RPA growth in both groups (RPA/LPA: RV-PA = 1.21, mBTS = 1.29, P = 1.0). Patients with RV-PA shunts experienced more frequent shunt stenosis compared to patients with mBTS (26 vs 2, P < 0.010). Freedom from shunt failure was 83.3 ± 3.2% and 94 ± 2% at 6 months in the RV-PA and mBTS groups, respectively (P = 0.003).

PA growth is significantly better in patients who received an mBTS. Moreover, patients with an RV-PA shunt more frequently experienced shunt failure due to shunt stenosis. However, survival after the NW procedure is not shunt dependent and growth of the LPA is less pronounced than RPA, regardless of the shunt type.