Source Of Pulmonary Blood Flow Research Articles

Short-Term Outcomes, Functional Status, and Risk Factors for Requiring Extracorporeal Life Support After Norwood Operation: A Single-Center Retrospective Study.

Patients requiring extracorporeal life support (ECLS) post-Norwood operation constitute an extremely high-risk group. We retrospectively described short-term outcomes, functional status, and assessed risk factors for requiring ECLS post-Norwood operation between January 2010 and December 2020 in a high-volume center. During the study period, 269 patients underwent a Norwood procedure of which 65 (24%) required ECLS. Of the 65 patients, 27 (41.5%) survived to hospital discharge. Mean functional status scale (FSS) score at discharge increased from 6.0 on admission to 8.48 (p < 0.0001). This change was primary in feeding (p < 0.0001) and respiratory domains (p = 0.017). Seven survivors (26%) developed new morbidity, and two (7%) developed unfavorable functional outcomes. In the regression analysis, we showed that patients with moderate-severe univentricular dysfunction on pre-Norwood transthoracic echocardiogram (odds ratio [OR] = 6.97), modified Blalock Taussig Thomas (m-BTT) shunt as source of pulmonary blood flow (OR = 2.65), moderate-severe atrioventricular valve regurgitation on transesophageal echocardiogram (OR = 8.50), longer cardiopulmonary bypass time (OR = 1.16), longer circulatory arrest time (OR = 1.20), and delayed sternal closure (OR = 3.86), had higher odds of requiring ECLS (p < 0.05). Careful identification of these risk factors is imperative to improve the care of this high-risk cohort and improve overall outcomes.

Comparison of the Effectiveness of Ductus Arteriosus Stenting and Systemic-to-Pulmonary Artery Shunt Placement in a Cohort of Newborns with Duct-Dependent Pulmonary Circulation

Comparison of the Effectiveness of Ductus Arteriosus Stenting and Systemic-to-Pulmonary Artery Shunt Placement in a Cohort of Newborns with Duct-Dependent Pulmonary Circulation

Echocardiographic measured shunt velocity does not predict pulmonary blood flow in patients with Blalock-Thomas-Taussig shunt.

Catheterisation is the gold standard used to evaluate pulmonary blood flow in patients with a Blalock-Thomas-Taussig shunt. It involves risk and cannot be performed frequently. This study aimed to evaluate if echocardiographic measurements obtained in a clinical setting correlate with catheterisation-derived pulmonary blood flow in patients with a Blalock-Thomas-Taussig shunt as the sole source of pulmonary blood flow. Chart review was performed retrospectively on consecutive patients referred to the catheterisation lab with a Blalock-Thomas-Taussig shunt. Echocardiographic parameters included peak, mean, and diastolic gradients across the Blalock-Thomas-Taussig shunt and forward and reverse velocity time integral across the distal transverse aorta. In addition to direct correlations, we tested a previously published formula for pulmonary blood flow calculated as velocity time integral across the shunt × heart rate × Blalock-Thomas-Taussig shunt area. Catheterisation parameters included pulmonary and systemic blood flow as calculated by the Fick principle. 18 patients were included. The echocardiography parameters and oxygen saturation did not correlate with catheterisation-derived pulmonary blood flow, systemic blood flow, or the ratio of pulmonary to systemic blood flow. As the ratio of reverse to forward velocity time integral across the transverse aorta increased, the probability of shunt stenosis decreased. Echocardiographic measurements obtained outside the catheterisation lab do not correlate with catheterisation-derived pulmonary blood flow. The ratio of reverse to forward velocity time integral across the transverse aortic arch may be predictive of Blalock-Thomas-Taussig shunt narrowing; this finding should be investigated further.

Fetal pulmonary valvuloplasty for pulmonary atresia with intact ventricular septum: a single-center clinical experience.

Fetal pulmonary valvuloplasty for pulmonary atresia with intact ventricular septum: a single-center clinical experience.

Abstract 11006: Fick’s versus Cardiac MRI Measured Pulmonary Blood Flow in Pre-Fontan Assessment

Background: Fick’s principle (FP) is unreliable if there are two sources of pulmonary blood flow (Q p ) with different saturations. We compared Q p and pulmonary vascular resistance (PVRI) measured by cardiac MRI (CMR) and FP in pre-Fontan patients. Material and Methods: Retrospective analysis of CMR and catheterization data obtained under the same general anesthetic from Jan 2009 to March 2021. FP derived Q p and PVRI used assumed O 2 consumption from Sackler’s equation. Paired T test was used for comparison between FP and CMR parameters. Results: 98 patients, with (mean ± sd): age 3.01±1.38 years and weight 13.31±2.4 kg. The FP derived Q p was 2.5(± 0.58) L/min/m 2 and PVRI1.91±0.61 Woods units*m 2 (WU*m 2 ). CMR measured pulmonary arterial flow (Q pa ) and pulmonary venous flow (Q pv ) were 1.97±0.55 L/min/m 2 and 3.49±0.76 L/min/m 2 , respectively. The PVRI using CMR Q pv was 1.38±0.47 WU*m 2 . The paired mean differences between Q p by FP and CMR Q pa or CMR Q pv were 0.53 (95%CI 0.41, 0.66; p&lt;0.001) and -0.98(95%CI -1.13, -0.83; p&lt;0.001), respectively. The paired mean difference between PVRI by FP and PVRI by CMR Qpv was 0.53(95%CI 0.44, 0.61; p&lt;0.001). The difference between CMR Q pv and FP derived Q p were correlated with aortopulmonary collateral flow (Pearson r=0.615, p&lt;0.001). PVRI derived from FP (1.91±0.61 WU*m 2 ) was higher than that from CMR (1.38±0.47, p&lt;0.001). However, this only resulted in one FP based PVRI estimate being &gt;4.0WU*m 2 when the CMR PVRI was &lt;4.0WU*m 2 . Conclusion: s: FP derived Q p is lower than CMR Q pv resulting in higher PVRI estimates by FP. In most patients this will not affect clinical risk stratification based on PVRI. In high-risk candidates for the Fontan, CMR based flow measurements are preferrable.

Abstract 15341: Persistent Fifth Arch as an Aortopulmonary Connection in a Case of Tetralogy of Fallot

Persistent fifth aortic arch is a heterogeneous vascular anomaly with variable anatomical presentations and physiological consequences. This unusual embryological remnant represents a management challenge, particularly in critical right sided obstructive heart lesions where accurate delineation of sources of pulmonary blood flow is essential. This is a newborn 2 kg premature male born at 34 weeks of gestation with prenatally diagnosed tetralogy of Fallot. Post-natal echocardiogram confirmed diagnosis with evidence of moderate-to-severe pulmonary stenosis, restrictive ventricular septal defect, and a right aortic arch. CT angiogram ordered to delineate the head and neck vessel anatomy showed an exceedingly rare finding of an isolated connection of the left subclavian artery (LSCA) to the main pulmonary artery (MPA) via a left sided ductus arteriosus. Blood flowed from the common carotid arteries, through the circle of Willis, and, in a retrograde direction, into the LSCA. Prostaglandin E was initiated due to concern for ductal dependent pulmonary blood flow, but after clinical observation it was discontinued without subsequent onset of cyanosis. Repeat echocardiograms were reassuring in showing persistence of the left ductus arteriosus. The patient was discharged home at 5 weeks-old and at 4 months-old he underwent complete repair after developing progressive desaturations and worsening sub-valvar and valvar pulmonary stenosis. The surgical repair included ventricular septal defect closure, transannular patch, extensive right ventricular myomectomy and reimplantation of LSCA onto the left common carotid artery. The post-operative course was uncomplicated. This rare case of persistent fifth aortic arch with retrograde flow to the LSCA demonstrates the complementary roles of noninvasive imaging modalities in guiding medical therapy and surgical management. This unusual blood flow pattern and initial concern for duct dependent pulmonary blood flow complicated early management, but a conservative approach with repeat imaging allowed for eventual complete repair.

Impact of Reintervention During Stage 1 Palliation Hospitalization: A National, Multicenter Study

BackgroundStage 1 palliation (S1P) for hypoplastic left heart syndrome remains associated with high morbidity and mortality. Previous studies on burden of reinterventions did not include patients who remain hospitalized before stage 2 palliation (S2P). This study described the rate of reintervention during S1P hospitalization and sought to determine the impact of reintervention on outcomes. MethodsAll participants enrolled in phase II of the National Pediatric Cardiology Quality Improvement Collaborative after S1P were included in this study. The primary outcome was the rate of reintervention during hospitalization after S1P and before hospital discharge or S2P. Reintervention was defined as 1 or more unplanned interventional cardiac catheterizations or surgical reoperations. ResultsBetween March 1, 2016 and October 1, 2019, 1367 participants underwent S1P and 339 (24.8%) had a reintervention; most commonly to address the source of pulmonary blood flow. Gestational age, weight at S1P, atrioventricular septal defect, heterotaxy, preoperative pulmonary artery bands, hybrid S1P, and an additional bypass run or early extracorporeal membrane oxygenation were significantly associated with reintervention. Participants in the reintervention group experienced higher rates of nearly all postoperative complications, were less likely to be discharged before S2P (57.1% vs 86%; P < .001), and more likely to experience in-hospital mortality (17% vs 5%; P < .001). ConclusionsUnplanned reintervention during hospitalization after S1P palliation occurred in 25% of participants in a large, registry-based national cohort. Participants who underwent reintervention were more likely to remain as inpatient and were less likely to survive to S2P. Reintervention was associated with a multitude of postoperative complications that affect survival and long-term outcome.

Hypoplastic Left Heart Syndrome: Definition, Morphology, and Classification.

This manuscript will provide information about hypoplastic left heart syndrome (HLHS) and related malformations, including definitions, morphology, and classification, based on the 2021 International Paediatric and Congenital Cardiac Code (IPCCC) and the Eleventh Revision of the International Classification of Diseases (ICD-11). HLHS is defined as "a spectrum of congenital cardiovascular malformations with normally aligned great arteries without a common atrioventricular junction, characterized by underdevelopment of the left heart with significant hypoplasia of the left ventricle including atresia, stenosis, or hypoplasia of the aortic or mitral valve, or both valves, and hypoplasia of the ascending aorta and aortic arch." Functionally univentricular heart is defined as "a spectrum of congenital cardiac malformations in which the ventricular mass may not readily lend itself to partitioning that commits one ventricular pump to the systemic circulation, and another to the pulmonary circulation." The Norwood operation is synonymous with the term "Norwood (Stage 1)" and is defined as (1) creation of an aortopulmonary connection and neoaortic arch construction resulting in univentricular physiology and (2) creation of a controlled source of pulmonary blood flow with a calibrated systemic-to-pulmonary artery shunt, a right ventricle to pulmonary artery conduit, or rarely, a cavopulmonary connection. The goals of the Norwood (Stage 1) Operation are creation of (1) unobstructed systemic blood flow via aortopulmonary connection and neoaortic arch construction, (2) unobstructed coronary blood flow, (3) unobstructed flow across the atrial septum, and (4) controlled pulmonary blood flow.

Hemodynamic effects of pulmonary regurgitation in one and one-half ventricle repair.

The pulmonary circulation after one and one-half ventricle repair is complex because of the direct connection of two sources of blood flow. Associated pulmonary regurgitation further complicates the pulmonary circulation. We report the complex hemodynamics depicted by phase-contrast magnetic resonance imaging in a patient with one and one-half ventricle circuit and severe pulmonary regurgitation. Antegrade superior vena caval flow occurred almost exclusively during diastole and regurgitated into the right ventricle. Consequently, the entire systemic venous return reached the right ventricle during diastole and is pumped back into the pulmonary arteries in systole. The case highlights the importance of analyzing flow patternsphase-by phase throughout the cardiac cycle instead of relying on the net flow volumes through each source of pulmonary blood flow.

Clinical implications of acute shunt thrombosis in paediatric patients with systemic-to-pulmonary shunt re-interventions.

Systemic-to-pulmonary shunts are used as a source of pulmonary blood flow in palliated Congenital Heart Disease in neonates and young infants. Shunt thrombosis, often requiring shunt interventions during index hospitalisation, is associated with poor outcomes. We hypothesised that extensive use of perioperative pro-coagulant products may be associated with shunt thrombosis. Children (≤18 years) undergoing systemic-to-pulmonary shunts with in-hospital shunt reinterventions between 2016 and 2020 were reviewed retrospectively. Perioperative associations to shunt thrombosis were examined by univariate logistic regression and Wilcoxon rank sum tests as appropriate. Cox and log transformed linear regression were used to analyse postoperative ventilation duration, length of stay, and cost. Of 71 patients requiring in-hospital shunt intervention after systemic-to-pulmonary shunts, 10 (14%) had acute shunt thrombosis, and among them five (50%) died. The median age was four (interquartile range: 0-15) months. There were 40 (56%) males, 41 (58%) had single ventricle anatomy, and 29 (40%) were on preoperative anticoagulants. Patients with acute shunt thrombosis received greater volume of platelets (p = 0.04), cryoprecipitate (p = 0.02), and plasma (p = 0.04) postoperatively in the ICU; experienced more complications (p = 0.01) including re-exploration for bleeding (p = 0.008) and death (p = 0.02), had longer hospital length of stays (p = 0.004), greater frequency of other arterial/venous thrombosis (p = 0.02), and greater hospital costs (p = 0.002). Patients who develop acute shunt thrombosis receive more blood products perioperatively and experience worse hospital outcomes and higher hospital costs. Future research on prevention/early detection of shunt thrombosis is needed to improve outcomes in infants after systemic-to-pulmonary shunt surgery.

Calculation of hemodynamics by the Fick method in pulmonary hypertension associated with congenital heart defects

In December, 2021 at the IXth All-Russian Congress «Pulmonary Hypertension – 2021» the first Eurasian guidelines for the diagnosis and treatment of pulmonary hypertension associated with congenital heart disease (CHD) in adults were approved. In this review, the expert group presents the basic principles of calculating hemodynamics according to Fick for the systemic and pulmonary circulation. The method is indispensable for congenital heart defects. Theoretical and practical aspects of calculating hemodynamics with arteriovenous, venoarterial and bidirectional shunting are considered. The calculation of the cardiac index of each of the circles of blood circulation is performed on the basis of oxygen consumption, the oxygen capacity of the blood and the oxygen arteriovenous difference of each of the circles of blood circulation. Formulas are given for calculating the cardiac index of the systemic and pulmonary circulation, the cardiac index of effective blood flow, arteriovenous and venoarterial shunt, pulmonary and peripheral vascular resistance, as well as the classical table and the LaFarge and Miettinen formula for the calculated oxygen consumption depending on gender, age and heart rate. The review is illustrated with three clinical examples. Calculation of hemodynamics according to Fick should be started after getting acquainted with the anatomy and clinic of congenital heart disease: diagnosis, typical hemodynamic disorders, number and possible direction of shunts, saturation by pulse oximeter on the arms and legs; a purely mechanistic approach that does not take into account the clinical picture can reduce the information content and reliability of the method. The Fick method is somewhat limited by the impossibility of catheterization of the left atrium with an intact interatrial septum. Inaccuracies that are possible when assessing absolute indicators by the indirect Fick method are leveled when calculating their relative values, and the values are identical in reliability to the direct method. The Fick method, due to the obviously high error, is not advisable to use if there is another source of pulmonary blood flow besides the pulmonary artery system, as well as with a low arteriovenous difference in circulatory circles.

Is More Better or Is Less More?

In staged palliation for single-ventricle congenital heart disease, the debate over whether adding or maintaining an additional source of pulmonary blood flow (APBF) at the time of the superior cavopulmonary connection (SCPC) has waged for several decades. All studies addressing this topic had retrospective single-center designs with heterogeneous patient populations. These studies commonly use surgeon preference as the indication to add, maintain, or eliminate APBF at SCPC. In one metaanalysis, the methodology used for some of these analyses was judged to be poor. 1 Alghamdi A.A. Bidirectional Glenn with additional pulmonary blood flow: systematic review and evidence-based recommendations. J Card Surg. 2015; 30: 724-730 Crossref PubMed Scopus (5) Google Scholar Not surprisingly, the findings from this collective work have been inconsistent. For example, proponents of adding APBF to SCPC cite higher peripheral oxygen saturations (Spo2) after the SCPC, improved pulmonary artery (PA) growth during the interval between SCPC and Fontan completion, and intentionally delaying Fontan surgery to allow for somatic growth as benefits of this strategy. 2 Ferns S.J. El Zein C. Multani K. et al. Is Additional pulsatile pulmonary blood flow beneficial to patients with bidirectional Glenn?. J Thorac Cardiovasc Surg. 2013; 145: 451-454 Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar ,3 Gray R.G. Altmann K. Mosca R.S. et al. Persistent antegrade pulmonary blood flow post-Glenn does not alter early post-Fontan outcomes in single-ventricle patients. Ann Thorac Surg. 2007; 84: 888-893 Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar However, the oxygen saturation difference between patients with and without APBF at SCPC is typically clinically modest and may become indistinguishable before the Fontan procedure. Data to show that any measured increase in PA size with APBF is sustained after the Fontan procedure or improves Fontan outcomes in the long term are lacking. Moreover, any extended time for somatic growth between SCPC and the Fontan operation in the patients with APBF would a priori allow for PA growth as well. Therefore, the link between preserved APBF at SCPC and durable benefit or sustained improved outcomes is weak on the basis of available information. Influence of Antegrade Pulmonary Blood Flow on Outcomes of Superior Cavopulmonary ConnectionThe Annals of Thoracic SurgeryVol. 114Issue 5PreviewWe sought to characterize short- and long-term outcomes after superior cavopulmonary connection (SCPC) in children eligible for inclusion of antegrade pulmonary blood flow (APBF) in the SCPC circuit, exploring whether maintaining APBF was associated with outcomes. Full-Text PDF

The Modern Surgical Approach to Pulmonary Atresia with Ventricular Septal Defect and Major Aortopulmonary Collateral Arteries.

Pulmonary atresia with ventricular septal defect and major aortopulmonary collaterals is a complex congenital heart defect that includes a heterogeneous subgroup of patients. Variation in the sources of pulmonary blood flow contributes to the complexity of the lesion and the diversity of approaches to its management. Unifocalization and rehabilitation focus on mobilization of collateral arteries and growth of native pulmonary arteries, respectively, with the ultimate surgical goal of achieving separated systemic and pulmonary circulations with the lowest possible right ventricular pressure. Regardless of the strategy, outcomes have altered the natural history of the disease, with a complete repair rate of approximately 80% and low early and late mortality rates. Given this heterogeneity of pulmonary vasculature, a tailored approach should be adopted for each patient, using all diagnostic methods currently offered by technical developments.

Coronary artery-pulmonary artery fistula in pulmonary atresia with ventricular septal defect: report of two surgical cases.

Pulmonary atresia with ventricular septal defect is a complex congenital cardiac anomaly. The blood is supplied to the lungs through a patent ductus arteriosus, a major aortopulmonary collateral artery, or in very rare cases from a coronary artery-pulmonary artery fistula. We present two cases with coronary artery-pulmonary artery fistula which underwent surgical intervention. In our first patient, the main pulmonary artery was supplied from the left main coronary artery. In the second patient, the right pulmonary artery originated from the left main coronary artery and continued to the right lung posteriorly to the aorta, while the left pulmonary artery originated from the patent ductus arteriosus. The difference in our cases is that the coronary artery pulmonary artery fistulas behave like major aortopulmonary collateral arteries originating from the coronary arteries. These fistulas were the main source of pulmonary blood flow.

Perioperative and Anesthetic Considerations in Tetralogy of Fallot With Pulmonary Atresia.

Tetralogy of Fallot with pulmonary atresia (ToF-PA) is a rare diagnosis that includes an extraordinarily heterogeneous group of complex anatomical findings with significant implications for physiology and prognosis. In addition to the classic findings of ToF, this particular diagnosis is characterized by complete failure of forward flow from the right ventricle to the pulmonary arterial system. As such, pulmonary blood flow is entirely dependent on shunting from the systemic circulation, most frequently via a patent ductus arteriosus, major aortopulmonary collaterals, or a combination of the two. The pathophysiology of ToF-PA is largely attributable to the abnormalities of the pulmonary vasculature. Ultimately, these patients require operative intervention to create a reliable, controlled source of pulmonary blood flow and ideally complete intracardiac repair. Even after operative correction, these patients remain at risk for pulmonary arterial stenoses and pulmonary hypertension. Although there have been significant advances in surgical and interventional management of ToF-PA leading to dramatic improvements in survival and long-term functional status, there is ongoing debate about the optimal management strategy given the risk of development of irreversible abnormalities of the pulmonary vasculature and the morbidity and mortality associated with sometimes multiple, complex operative interventions often occurring early in infancy. This review will discuss the findings in patients with ToF-PA with a focus on the perioperative and anesthetic management and will highlight challenges faced by the anesthesiologist in caring for these patients.

Tetralogy of Fallot with pulmonary atresia and aortopulmonary window may mimic common arterial trunk.

Tetralogy of Fallot with pulmonary atresia is a group of congenital cardiac malformations, which is defined by the absence of luminal continuity between both ventricles and the pulmonary artery, and an interventricular communication. Pulmonary arterial supply in patients with tetralogy of Fallot with pulmonary atresia can be via the arterial duct or from collateral arteries arising directly or indirectly from the aorta (systemic-to-pulmonary artery collaterals), or rarely both. The rarest sources of pulmonary blood flow are aortopulmonary window and fistulous communication with the coronary artery.Herein, we describe an outflow tract malformation, tetralogy of Fallot with pulmonary atresia and aortopulmonary window, which was misdiagnosed as common arterial trunk. We emphasise the morphological differences.

Accuracy of Fetal Echocardiography in Defining Pulmonary Artery Anatomy and Source of Pulmonary Blood flow in Pulmonary Atresia with Ventricular Septal Defect (PA/VSD).

Precise delineation of central and branch pulmonary artery anatomy, patent ductus arteriosus, and major aorto-pulmonary collateral artery anatomy in the fetal diagnosis of pulmonary atresia with ventricular septal defect is challenging but important to prenatal counseling and postnatal management. We aimed to evaluate the accuracy of fetal echocardiography to determine these anatomical nuances in pulmonary atresia with ventricular septal defect. This was a retrospective, single-institution, 10-year chart review of consecutive prenatal diagnosis of pulmonary atresia with ventricular septal defect for assessment of pulmonary artery, patent ductus arteriosus, and major aorto-pulmonary collateral artery anatomy and comparison with postnatal imaging including echocardiography, cardiac catheterization, and computerized tomography angiography. Twenty-six fetuses were diagnosed with pulmonary atresia with ventricular septal defect during the review period and complete postnatal follow-up was available in 18, all confirming the basic prenatal diagnosis. Fetal echocardiography accurately predicted central and branch pulmonary artery anatomy in 16 (89%) [confluent in 14, discontinuous in 2], patent ductus arteriosus status in 15 (83%) [present in 10, absent in 5], and major aorto-pulmonary collateral arteries in 17 (94%) [present in 9, absent in 8]. Accuracy increased to 100% for pulmonary artery anatomy (16/16) and major aorto-pulmonary collateral artery (17/17) when excluding patients whose anatomy was reported as uncertain on fetal echocardiography. Fetal echocardiography can provide accurate anatomical details in the vast majority of fetuses with pulmonary atresia with ventricular septal defect. This allows for more anatomy-specific counseling, prognostication, and improved selection of postnatally available management options.

Patent Ductus Arteriosus Stenting for All Ductal-Dependent Cyanotic Infants: Waning Use of Blalock-Taussig Shunts.

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Isolated left subclavian with a compensatory ductus in a child with Tetralogy of Fallot.

Tetralogy of Fallot is a cyanotic heart disease wherein aortopulmonary collaterals serve as source of pulmonary blood flow to maintain oxygenation. We report an incidentally detected isolated left subclavian artery supplying a compensatory ductus in a child with Tetralogy of Fallot that effectively contributed as a de novo palliative systemic to pulmonary artery shunt. Clinically, the entity could not be suspected, as the child did not have symptoms suggestive of arterial insufficiency of the left arm or weak pulses or neurological symptoms. The child underwent successful intracardiac repair with a reimplantation of left subclavian artery to left common carotid artery.

Patent ductus arteriosus stenting for ductal dependent pulmonary blood flow

Neonates with ductal-dependent blood flow require a stable source of pulmonary blood flow as their initial palliative procedure. This may be accomplished with either a surgical shunt, e.g., a Blalock- Taussig- Thomas (BTT) shunt, or with a patent ductus arteriosus (PDA) stent. Based on recent data, including data from large multicenter studies, PDA stenting has not only emerged as an acceptable alternative to the BTT shunt but the preferred method to establish a stable source of pulmonary blood flow in most circumstances. Advances in procedural details, technical aspects, and an understanding of ductal morphology have greatly facilitated PDA stenting in the current era, though a steep learning curve is involved. A collaborative effort from multiple specialties including congenital interventional cardiology and congenital heart surgery is needed to take care of this high-risk patient population.