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Are early palliative procedures providing an adequate long-term benefit in young cyanotic infants from developing
Pramod Sagar1, Kothandam Sivakumar1, Koneru L Umamaheshwar1
1Department of Pediatric Cardiology, Institute of Cardio Vascular Diseases, Madras Medical Mission, Chennai, India.
Insights
Cyanotic infants undergoing palliation with ductal stents, pulmonary outflow stents, or aortopulmonary shunts face high inter-stage mortality. Duct stenting shows promise for specific conditions like univentricular hearts, offering better long-term outcomes in resource-restricted settings.
Area of Science:
- Pediatric Cardiology
- Congenital Heart Disease
- Interventional Cardiology
Background:
- Reduced pulmonary blood flow in neonates and infants often requires palliative interventions like ductal stents, right ventricular outflow tract stents, and aortopulmonary shunts.
- Long-term outcomes of these palliative procedures in resource-restricted countries are not well-documented.
Purpose of the Study:
- To evaluate the technical success, mortality rates, re-intervention needs, and duration of palliation for different procedures in infants.
- To compare outcomes based on patient anatomy and the type of palliative intervention used.
Main Methods:
- A retrospective, single-centre observational study analyzed data from 69 infants weighing ≤5 kg who underwent aortopulmonary shunts, ductal stents, or pulmonary outflow stents.
- Patients were categorized by their specific cardiac anatomy to assess procedural outcomes.
Main Results:
- Technical success rates were high: 90% for shunts, 91% for outflow stents, and 100% for ductal stents.
- Early mortality (30-day) ranged from 9% to 20%, and late mortality was observed in 15-20% of patients across all procedures.
- Ductal stenting in univentricular hearts and pulmonary atresia with an intact ventricular septum showed favorable outcomes, while biventricular repair was achieved in 63% of patients.
Conclusions:
- Despite technically successful palliation, cyanotic infants experience significant inter-stage mortality regardless of the intervention type.
- Ductal stenting appears to offer better long-term results for specific congenital heart conditions, particularly in resource-limited settings.
- Achieving biventricular repair remains a challenge in developing countries, highlighting the need for improved strategies and care.
Objectives:
Ductal stents, right ventricular outflow tract stents, and aortopulmonary shunts are used to palliate newborns and infants with reduced pulmonary blood flow. Current long-term outcomes of these palliations from resource-restricted countries are unknown.
Methods:
This single-centre, retrospective, observational study analysed the technical success, immediate and late mortality, re-interventions, and length of palliation in infants ≤5 kg who underwent aortopulmonary shunts, ductal, and pulmonary outflow stents. Patients were grouped by their anatomy.
Results:
There were 69 infants who underwent one of the palliations. Technical success was 90% for aortopulmonary shunts (n = 10), 91% for pulmonary outflow stents (n = 11) and 100% for ductal stents (n = 48). Early mortality within 30 days in 12/69 patients was observed in 20% after shunts, 9% after pulmonary outflow stents, and 19% after ductal stents. Late mortality in 11 patients was seen in 20% after shunts, 18% after outflow stents, and 15% after ductal stents. Seven patients needed re-interventions; two following shunts, one following outflow stent, and four following ductal stents for hypoxia. Among the anatomical groups, 10/12 patients with pulmonary atresia, intact ventricular septum survived after valvotomy and ductal stenting. Survival to Glenn shunt after ductal stent for pulmonary atresia, intact ventricular septum and diminutive right ventricle was very low in two out of eight patients, but very good (100%) for other univentricular hearts. Among 35 patients with biventricular lesions, 22 survived to the next stage.
Conclusions:
Cyanotic infants, despite undergoing technically successful palliation had a high inter-stage mortality irrespective of the type of palliation. Duct stenting in univentricular hearts and in pulmonary atresia with an intact ventricular septum and adequate sized right ventricle tended to have low mortality and better long-term outcome. Completion of biventricular repair after palliation was achieved only in 63% of patients, reflecting unique challenges in developing countries despite advances in intensive care and interventions.
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