Isolated left pulmonary artery of ductal origin: Reconstruction using pedicled main pulmonary artery flap.

Patent Ductus Arteriosus.

Patent ductus arteriosus (PDA) stenting is evolving as the preferred method for establishing stable pulmonary blood flow in cyanotic infants, offering lower mortality, faster recovery, and shorter hospital stays. However, stenting may lead to branch pulmonary artery (BPA) jailing, potentially restricting blood flow to the jailed branch. This study analyzes patient characteristics, cardiovascular anatomy, stenting techniques, and outcomes involving BPA jailing where the BPA originates from the PDA, with a focus on the growth of the jailed BPA. A retrospective review was conducted of infants with duct-dependent pulmonary blood flow who underwent PDA stenting at Rady Children's Hospital San Diego from 2013 to 2024. Of 70 infants, 22 (31%) experienced BPA jailing due to the BPA originating from the PDA. The median age and weight at stenting were 9.5days and 3275g, with PDA as the sole source of pulmonary blood flow in 72% of cases. PDA type III was the most prevalent (77%). The jailed BPA showed significant distal growth (mean Nakata index increase of 117.35 mm2/m2, p = 0.0001), with symmetry maintained. Re-intervention for hypoxia was required in 55% of cases and involved ballooning, re-stenting, and strut dilation. There were no 30-day mortalities (2 late deaths occurred). Progression to Glenn palliation occurred in 12 patients, 5 had a definitive repair, 1 underwent left pulmonary artery plasty and a BT shunt and 2 await repair. PDA stenting in infants with a BPA originating from the PDA is feasible with notable distal BPA growth despite frequent re-interventions. Patients maintained pulmonary artery symmetry with excellent survival.

Introduction: In patients with cyanotic congenital heart disease (CHD) and ductal-dependent pulmonary blood flow (DDPBF), initial palliation may include patent ductus arteriosus (PDA) stent or Blalock-Thomas-Taussig shunt (BTTS). This meta-analysis aimed to compare outcomes after PDA stent and BTTS. Methods: A comprehensive search of PubMed and Embase databases was performed. Newcastle-Ottawa tool assessed risk of bias in observational studies. Odds ratios and hazard ratios were pooled. Adjusted hazard ratios controlled for covariates and assessed time to event in survival analysis. Meta-analysis was performed using DerSimonian-Laird random-effects models. Results: Six retrospective observational studies were included, all low risk of bias. Of 757 patients, 243 (32.1%) had PDA stent and 514 (67.9%) had BTTS. There was no significant difference in mortality between PDA stent (HR 0.71; 95% CI: 0.26-1.93, p=0.50; I 2 =54%) and BTTS. PDA stent was associated with lower risk of complications (OR 0.45; 95% CI: 0.25-0.81, p=0.008; I 2 =0%) and post-procedural mechanical circulatory support (OR 0.27; 95% CI: 0.09-0.79, p=0.02; I 2 =0%). PDA stent was associated with shorter intensive care unit (-4.03 days; 95% CI: -5.99 to -2.07, p<0.001; I 2 =66%) length of stay (LOS), hospital LOS (-5.54 days; 95% CI: -9.20 to -1.88, p=0.003; I 2 =78%) and duration of mechanical ventilation (-3.41 days; 95% CI -5.29 to -1.52, p<0.001; I 2 =88%). There were no differences in pulmonary artery growth or hazard of unplanned reinterventions to treat cyanosis between groups. Conclusions: In this large meta-analysis of cyanotic CHD and DDPBF, initial palliation with PDA stent or BTTS demonstrated similar risks of mortality and unplanned reintervention to treat cyanosis. PDA stent was associated with fewer complications and shorter hospital LOS. Given limitations inherent to observational study, this analysis supports the development of a randomized clinical trial in this population.

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.

Infants with ductal-dependent pulmonary blood flow may undergo palliation with either a patent ductus arteriosus (PDA) stent or a modified Blalock-Taussig (BT) shunt. A balanced multicenter comparison of these 2 approaches is lacking. Infants with ductal-dependent pulmonary blood flow palliated with either a PDA stent or a BT shunt from January 2008 to November 2015 were reviewed from the 4 member centers of the Congenital Catheterization Research Collaborative. Outcomes were compared by use of propensity score adjustment to account for baseline differences between groups. One hundred six patients with a PDA stent and 251 patients with a BT shunt were included. The groups differed in underlying anatomy (expected 2-ventricle circulation in 60% of PDA stents versus 45% of BT shunts; P=0.001) and presence of antegrade pulmonary blood flow (61% of PDA stents versus 38% of BT shunts; P<0.001). After propensity score adjustment, there was no difference in the hazard of the primary composite outcome of death or unplanned reintervention to treat cyanosis (hazard ratio, 0.8; 95% confidence interval [CI], 0.52-1.23; P=0.31). Other reinterventions were more common in the PDA stent group (hazard ratio, 29.8; 95% CI, 9.8-91.1; P<0.001). However, the PDA stent group had a lower adjusted intensive care unit length of stay (5.3 days [95% CI, 4.2-6.7] versus 9.19 days [95% CI, 7.9-10.6]; P<0.001), a lower risk of diuretic use at discharge (odds ratio, 0.4; 95% CI, 0.25-0.64; P<0.001) and procedural complications (odds ratio, 0.4; 95% CI, 0.2-0.77; P=0.006), and larger (152 mm2/m2 [95% CI, 132-176] versus 125 mm2/m2 [95% CI, 113-138]; P=0.029) and more symmetrical (symmetry index, 0.84 [95% CI, 0.8-0.89] versus 0.77 [95% CI, 0.75-0.8]; P=0.008] pulmonary arteries at the time of subsequent surgical repair or last follow-up. In this multicenter comparison of palliative PDA stent and BT shunt for infants with ductal-dependent pulmonary blood flow adjusted for differences in patient factors, there was no difference in the primary end point, death or unplanned reintervention to treat cyanosis. However, other markers of morbidity and pulmonary artery size favored the PDA stent group, supporting PDA stent as a reasonable alternative to BT shunt in select patients.

Cardiac Operations After Patent Ductus Arteriosus Stenting in Duct-Dependent Pulmonary Circulation

Background: Bilateral banding of the branches of the pulmonary artery in patients with hypoplastic left heart syndrome (HLHS) and other duct dependent critical neonatal heart malformations can significantly reduce the incidence of severe complications in the postoperative period, especially in severely unstable patients. In our study we compared different surgical techniques of bilateral pulmonary artery banding (PAB) in respect to their success in balancing systemic and pulmonary blood flow. Methods: We included 44 neonates with a HLHS and congenital heart diseases (CHD) with a functional single ventricle underwent a hybrid operation: bilateral PAB and patent ductus arteriosus stenting. The hybrid surgery for method No. 1 is performed as a one-stage procedure, together with patent ductus arteriosus (PDA) stenting. After median sternotomy, two Gore-Tex 1–2 mm wide bands with a diameter of 3–3.5 mm are put. When we apply method No. 2 then the thread is used to create bands. Method No. 3 is distinguished by intraoperative assessment of blood flow at the site of narrowing of the branches of the pulmonary artery and optional stenting of the PDA. The cuff for banding is made of Gore-Tex tubing. Effectiveness when applying method Nos. 1 and 2 is assessed by the change in invasive blood pressure and oxygen saturation after narrowing of the branches of the pulmonary artery. Also, with these techniques PDA stenting by inserting the introducer via pulmonary artery trunk is performed. Results: HLHS with mitral or aortic valve atresia or both was present in 19 patients (43.1%), with severe left heart obstruction resulting in PDA dependent systemic circulation in 16 babies (36.4%). CHD with single ventricle physiology occurred in 9 patients (20.5%). 14 babies (31.8%) undergo the procedure following the method No. 1, 8 patients (18.2%) method No. 2 and 22 patients (50%) method No. 3. Qp/Qs = 1/1 was achieved in 30 patients (30/44, 68.1%): as a result of the method No. 1 was achieved in 5 patients (5/14, 35.7%), method No. 2 in 4 patients (4/8, 50%), method No. 3 in 21 patients (21/22, 95.5%). Multivariate regression analysis revealed that method No. 3 significantly increases the chances of hemodynamic efficacy operations (OR = 35.0; p = 0.005; CI (95%) 3–411.5). Conclusion: Application of the operation technique No. 3 in combination with the intraoperative assessment of blood flow parameters at the site of banding of the branches of the pulmonary artery are the most optimal criteria for achieving Qp/Qs = 1/1. If there are signs of restriction at the level of the foramen ovale, atrioseptostomy should be done in the second stage after bilateral pulmonary banding.

Introduction: Hypoplastic left heart patients have significant blood flow unbalance in the cardiovascular system; excess blood flows from the right ventricles to the lung. Patent Ductus Arteriosus (PDA) stenting prevents excess blood flow and shunts the blood flow to the aorta through PDA without conventional heart surgeries. On the other hand, past clinical researches report that PDA stenting can bring on thrombosis around ductus arteriosus. This study elucidated the hemodynamics of the aorta-pulmonary artery system by using three patient-specific morphological data, experimentally and numerically. Methods: This study carried out Particle Image Velocimetry (PIV) measurement and Computational Fluid Dynamics (CFD) analysis for three patient-specific models. Results: The experimental and numerical analysis clarified transient hemodynamics in the aorta-pulmonary artery system; pulmonary blood flow was shunt to the aorta at the peak systole and diastole. Q-criterion, which indicates both the second-order invariant of turbulence flow and the structure’s characteristics, was generated in the PDA at the same period. Conclusion: This study found the influence of PDA morphology on transient hemodynamics; the highest Q-criterion in the PDA is 600 [s-2]; on the contrary, the lowest case is around 200 [s-2]. These flow characteristics are essential factors in thrombus formation in PDA.

Pulmonary arteries' (PAs) growth can be promoted by stenting of patent ductus arteriosus (PDA). This may result in better angle between the PDA and the PAs, allowing improved growth. In this study, we sought to evaluate the effect of PDA stenting on the growth of the pulmonary arteries by comparing their dimensions pre-stenting to their dimensions in the pre-second stage operations in patients with congenital heart diseases-duct-dependent pulmonary (CHD-DDP) circulation. Between January 2015 and December 2016, 58 neonates with CHD-DDP circulation underwent transcatheter PDA stenting and had evaluation of PAs growth before the second stage. Various parameters [Pre-branching right and left pulmonary artery (RPA, LPA) diameters, their Z scores, LPA/RPA ratio, McGoon's ratio and Nakata index] were recorded and compared pre-stenting and pre-second stage. The evaluation was done using catheterization or multislice computed tomography (MSCT). PDA stenting was successful in 49 patients out of 58 (84.5%) patients with an age of 13.5 ± 10.4days and a weight of 2.9 ± 0.5kg. Twenty-two (44.9%) patients had complex CHD-DDP, 14 (28.6%) patients had PA/IVS and 13 (26.5%) patients had PA/VSD. Pre-second stage RPA, LPA diameters and their Z scores increased significantly (RPA increased from 0.36 ± 0.05cm to 0.60 ± 0.11cm, P < 0.001, RPA Z-score increased from -1.29 ± 0.91 to 0.81 ± 0.18, P < 0.001; LPA increased from 0.34 ± 0.06cm to 0.58 ± 0.10cm, P < 0.001, LPA Z-score increased from -1.17 ± 0.86 to 0.97 ± 0.48, P < 0.001). McGoon's ratio increased significantly from 1.20 ± 0.11 to 1.61 ± 0.15 (P < 0.001). Nakata index increased from 105.94 ± 33.53 to 183.48 ± 40.58 mm2/m2 (P < 0.001). However, LPA/RPA ratio did not change (0.96 ± 0.05 and 0.98 ± 0.16, P = 0.288). PDA stenting is effective in promoting the global and the individual pulmonary artery growth in congenital heart diseases with duct-dependent pulmonary circulation. In this study, we presented our experience with this approach in 2 tertiary care centers in the DELTA region of Egypt. PDA stenting, generally, showed symmetric growth of the pulmonary arteries with comparable results to the international figures.

The aim of this study is to evaluate the impact of anticoagulation strategy, stent type, and pulmonary artery (PA) jailing on unplanned reintervention rates and PA growth in neonates undergoing patent ductus arteriosus (PDA) stenting. Specifically, we compared aspirin monotherapy versus aspirin plus Enoxaparin, bare metal versus drug-eluting stents, and jailed versus non-jailed PAs. A retrospective chart review was conducted on neonates who underwent PDA stenting between 2014 and 2024. Patients were categorized by stent type, anticoagulation regimen, and PA jailing status. Unplanned reintervention rates were assessed using chi-square analysis and logistic regression. PA growth was evaluated using catheterization, MRI, and CT imaging. Statistical analyses of PA growth included t-tests and regression models. Among 116 neonates analyzed, aspirin monotherapy was associated with a significantly lower unplanned reintervention rate compared to combination therapy with Enoxaparin (p = 0.0447). Stent type did not significantly impact reintervention rates. Additionally, intrapatient jailed PAs exhibited significantly reduced distal growth compared to non-jailed PAs (p = 0.0070). For neonatal PDA stenting, aspirin monotherapy may be as effective as aspirin plus Enoxaparin for post-stenting anticoagulation, and drug eluting stents may not have a significant benefit over bare metal stents. Furthermore, PA jailing may negatively impact distal vessel growth, highlighting the need for refined stent placement techniques, although further prospective studies are needed to optimize procedural strategies and long-term outcomes in this high-risk neonatal population.

ObjectivesPercutaneous patent ductus arteriosus (PDA) stenting is a therapeutic modality in patients with duct-dependent pulmonary circulation with reported success rates from 80–100%. The current study aims to assess the outcome and the indicators of success for PDA stenting in different ductal morphologies using various approaches.MethodsA prospective cohort study from a single tertiary center presented from January 2018 to December 2019 that included 96 consecutive infants with ductal-dependent pulmonary circulation and palliated with PDA stenting. Patients were divided according to PDA origin into 4 groups: Group 1: PDA from proximal descending aorta, Group 2: from undersurface of aortic arch, Group 3: opposite the subclavian artery, Group 4: opposite the innominate/brachiocephalic artery.ResultsThe median age of patients was 22 days and median weight was 3 kg. The procedure was successful in 78 patients (81.25%). PDA was tortuous in 70 out of 96 patients. Femoral artery was the preferred approach in Group 1 (63/67), while axillary artery access was preferred in the other groups (6/11 in Group 2, 11/17 in Group 3, 1/1 in Group 4, P <0.0001). The main cause of procedural failure was inadequate parked coronary wire inside one of the branch of pulmonary arteries (14 cases; 77.7%), while 2 cases (11.1%) were complicated by acute stent thrombosis, and another 2 cases with stent dislodgment. Other procedural complications comprised femoral artery thrombosis in 7 cases (7.2%). Patients with straight PDA, younger age at procedure and who had larger PDA at pulmonary end had higher odds for success (OR = 8.01, 2.94, 7.40, CI = 1.011–63.68, 0.960–0.99, 1.172–7.40,respectively, P = 0.048, 0.031,0.022 respectively).ConclusionsThe approach for PDA stenting and hence the outcome is markedly determined by the PDA origin and morphology. Patients with straight PDA, younger age at procedure and those who had relatively larger PDA at the pulmonary end had better opportunity for successful procedure.

The patent ductus arteriosus (PDA) is a vascular structure that connects the proximal descending aorta to the roof of the main pulmonary artery near the origin of the left branch pulmonary artery. This essential fetal structure normally closes spontaneously after birth. After the first few weeks of life, persistence of ductal patency is abnormal. The physiological impact and clinical significance of the PDA depend largely on its size and the underlying cardiovascular status of the patient. The PDA may be “silent” (not evident clinically but diagnosed incidentally by echocardiography done for a different reason), small, moderate, or large. Regardless of the size, complications may arise, and it is important for both pediatric and adult cardiologists to have an understanding of the pathophysiology, clinical implications, and management of PDA. The ductus arteriosus is a normal and essential fetal structure that becomes abnormal if it remains patent after the neonatal period. In normal cardiovascular development, the proximal portions of the sixth pair of embryonic aortic arches persist as the proximal branch pulmonary arteries, and the distal portion of the left sixth arch persists as the ductus arteriosus, connecting the left pulmonary artery with the left dorsal aorta (Figure 1). Normally, the distal right sixth aortic arch loses its connection to the dorsal aorta and degenerates. This transformation is complete by 8 weeks of fetal life. Figure 1. Schematic of embryonic aortic arch system. The 6 pairs of embryonic aortic arches are demonstrated (left-sided arches are numbered). The portions that normally involute are indicated by broken lines. The distal left sixth embryonic arch normally persists and becomes the PDA, connecting the left pulmonary artery to the proximal descending aorta. The right distal sixth arch normally involutes, as does the eighth segment of the right dorsal aorta (*), which results in a leftward aortic …

Patent ductus arteriosus (PDA) stent placement in infants with ductal-dependent pulmonary blood flow is being increasingly used in clinical practice. To correlate computed tomographic (CT) angiography morphology and length of the PDA with catheter angiography and its relation to eventual PDA stent length. We retrospectively identified all pediatric patients who underwent PDA stenting at our institute from 2004 to 2018. We included children who had CT angiography prior to stenting. PDA length was measured by a radiologist blinded to the catheter angiography data, using Syngo-via post-processing software (Siemens, Erlangen, Germany). Vessel centerline technique was used. We measured the actual length of the duct as well as straight length between aortic and pulmonary ends. PDA morphology tortuosity index was classified as straight (Type I), mildly tortuous with 1 turn (Type II) and tortuous with >1 turn (Type III), and the PDA origin was noted. The PDA was also measured and morphology classified on catheter angiography by an interventional cardiologist blinded to the CT angiography findings. We compared the CT angiography and catheter angiography lengths, straight lengths and stent length using scatter plots and intraclass correlation coefficient (ICC). A total of 83 children who had PDA stenting were identified, of whom 17 had prior CT angiography. Fifteen of these were neonates. There was agreement between CT angiography and catheter angiography regarding the PDA morphology tortuosity index in 94% of cases and PDA origin in 100% of cases. There was moderate agreement between CT angiography and catheter angiography actual and straight PDA lengths, with ICC coefficients of 0.65 and 0.68, respectively. There was moderate agreement between CT angiography actual length, CT angiography straight length, catheter angiography actual length and eventual stented PDA length, with ICCs of 0.57, 0.67 and 0.73, respectively. There was poor agreement between catheter angiography straight length and eventual stented PDA length, with an ICC of 0.39. PDA length and morphology description on CT angiography correlates well with catheter angiography and can be a reliable guide for the interventional cardiologist in decision-making regarding appropriate choice of PDA stent length.

Patent ductus arteriosus (PDA) stenting is evolving as an alternative to surgical aorto-pulmonary shunts for infants with ductal-dependent pulmonary blood flow. Given anatomical proximity, the PDA can compress the ipsilateral bronchus. We report a case series of four patients with bronchial compression by a tortuous PDA who underwent PDA stenting. Our four patients received PDA stents for ductal-dependent pulmonary blood flow despite preprocedure imaging evidence of bronchial compression. We reviewed the cross-sectional chest imaging to assess the degree of bronchial compression and the variables that affect it, namely PDA size, PDA tortuosity, and the anatomical relationship between the compressed bronchus and the PDA. Three out of the four patients had postprocedure imaging, and all showed relief of the previously seen bronchial compression. Post-PDA stenting patients had a smaller and straight PDA with significant lateralization away from the compressed bronchus. None of the four patients developed symptoms of bronchial compression poststenting. Our study suggests that pre-existing bronchial compression does not preclude PDA stenting. Stent placement in an engorged and tortuous PDA led to significant improvement in pre-existing bronchial compression. Improvement may be attributed to PDA shrinkage, straightening, and lateralization. Further studies are needed to confirm our findings.

53. Bilateral ductal stenting for nonconfluent pulmonary arteries in a newborn