Duct Dependent Pulmonary Blood Flow Stent or BT shunt? Mansour Al-Mutairi MD Consultant Pediatric cardiologist King Abdulaziz Cardiac Center Assistant Professor, Cardiac Sciences KSAU-HS, NGHA Riyadh , Saudi Arabia
Friend-ship and support make success
(Can be broken temporarily in Debate sessions in meeting !!!)
Duct Dependent Pulmonary Blood Flow Stent or BT shunt?
Goals to achieve:
4-6 months of adequate pulmonary blood supply Promoting global pulmonary artery growth Minimize sternotomies / thoracotomies as much as we could Minimize ICU and Hospital stay days as much as we could ( better and effective use of available resources)
Duct Dependent Pulmonary Blood Flow Stent or BT shunt?
Pre-determined Facility & Vision about the management plans: Single ventricle (SV) Biventricular repair (BV) Unclear anatomy ( time needed )
? DC PGE2 ( multiple co-morbidity, facilitate ICU and hospital discharge, nursing care)
PDA dependent Pulmonary Circulation PDA stent
Majority can be done (PDA & PA’s morphology!) Less invasive Minimal M&M ( high risk Pt) Adequate PBF Global PA growth Less distortion Easy ICU management Less ICU & Hospital stay
BT shunt
Duct Dependent Pulmonary Blood Flow Stent or BT shunt?
How bad is the B-T shunt?!
Duct Dependent Pulmonary Blood Flow Stent or BT shunt? Complications :
Early complications:
Late complications:
Shunt occlusion Bleeding Unilateral pulmonary oedema Phrenic nerve injury Diaphragmatic paralysis Limb ischemia ( quarter gangrene) Sudden death Wound infection Prolonged ICU stay Prolonged hospital stay Myocardial infarction (PA/IVS)
Distortion of pulmonary arteries Differential PA growth Shunt stenosis Calcifications of shunt Innominate artery steal (Cerebral flow) Differential forelimb growth Pseudo aneurysms Chylothorax Risk of scoliosis with neonatal thoracotomy others
h t a e D
Duct Dependent Pulmonary Blood Flow Stent or BT shunt?
%) 6 European Journal of Cardio-thoracic Surgery (2008) . 5 1 is S /IV A ty: % (P i l rta 7.2 o m a rt r o f r h e K g o rt s r o ula n 3 upp t c fa tric s tha ry s k Ris niven t les tilato •U eigh ven • W e-op •Pr Ann Thorac Surg 2011
Duct Dependent Pulmonary Blood Flow Stent or BT shunt?
Duct Dependent Pulmonary Blood Flow Stent or BT shunt?
Normal PA’s
Before BT shunt
RPA stenosis
LPA stenosis
After BT shunt
Duct Dependent Pulmonary Blood Flow Stent or BT shunt?
Normal PA’s
After Glenn
After Glenn
Duct Dependent Pulmonary Blood Flow Stent or BT shunt?
Normal PA’s
Complex CHD (LAI) After BT shunt > Pre-Glenn
Duct Dependent Pulmonary Blood Flow Stent or BT shunt?
PA/IVS RVDCC
After BT shunt on ECMO
Death
Duct Dependent Pulmonary Blood Flow Stent or BT shunt?
In spite of advance in surgical techniques, Shunt remains with “ Very high M&M”
Duct Dependent Pulmonary Blood Flow Stent or BT shunt? Struggle with B-T shunt 70 years (almost) 1944: Classic Blalock – Taussig Shunt.
Duct Dependent Pulmonary Blood Flow Stent or BT solution shunt? Temporary
PROBLEM
• • • •
Mod B-T shunt Central shunt Sternotomy (Thoracotomy) Close the PDA Vs. Keep PDA
Duct Dependent Pulmonary Blood Flow Stent or BT shunt?
Primary Neonatal repair
Duct Dependent Pulmonary Blood Flow Stent or BT shunt? Ann Thorac Surg 2010
• • • • • •
Restrictive physiology Effusion Longer ICU and Hospital stay Prolonged ventilation Ann Pediatr Card 2008 Inotropic support Increased morbidity ˃ repaired later
Duct Dependent Pulmonary Blood Flow Stent or BT shunt?
PROBLEM
• •
Don’t struggle & stop digging Interventional cardiologist ( not your enemy)
Duct Dependent Pulmonary Blood Flow Stent or BT shunt?
Duct Dependent Pulmonary Blood Flow Stent or BT shunt?
How good is the PDA stenting?!
Duct Dependent Pulmonary Blood Flow Stent or BT shunt?
When to stent the PDA ? •If palliation for few months •1st line of management •Irrespective of PDA anatomy •PA’s branch stenosis is not a contraindication ( BVR > SVR) •Patient weight ( prograde ≥ 2kg, retrograde 2.8kg)
Duct Dependent Pulmonary Blood Flow Stent or BT shunt?
• PA’s growth ? No concern ( ≥≥ shunt)
• Surgery after PDA stent ? Not an issue
• Hemodynamics ? No problem ( ˃ 25 patients who had a repeat cath their PAP & PVR where normal) We stop pre-Glenn cath in most patients
Duct Dependent Pulmonary Blood Flow Stent or BT shunt? November 2012
JACC 2009
J Interven Cardiol 2010 Ann Thoracic surg 2010
JACC 2004
Duct Dependent Pulmonary Blood Flow Stent or BT shunt?
Case 1 SV
Duct Dependent Pulmonary Blood Flow Stent or BT shunt? Single ventricle tract repair
PA/IVS RVDCC
at birth doing well waiting Glenn
Duct Dependent Pulmonary Blood Flow Stent or BT shunt? Single ventricle tract repair PA/IVS RVDCC
at birth doing well waiting Glenn
Duct Dependent Pulmonary Blood Flow Stent or BT shunt? Single ventricle tract repair PA/IVS RVDCC
at birth doing well waiting Glenn
Duct Dependent Pulmonary Blood Flow Stent or BT shunt?
Case 2 SV
Duct Dependent Pulmonary Blood Flow Stent or BT shunt? Single ventricle tract repair
PA & IVS at birth
Duct Dependent Pulmonary Blood Flow Stent or BT shunt? Single ventricle tract repair
PA & IVS at birth
Duct Dependent Pulmonary Blood Flow Stent or BT shunt? Single ventricle tract repair
PA & IVS at 6 months Pre-Glenn
PA & IVS Pre-Fontan
Duct Dependent Pulmonary Blood Flow Stent or BT shunt?
Case 3 SV
Duct Dependent Pulmonary Blood Flow Stent or BT shunt? Single ventricle tract repair
PA & IVS at birth
Duct Dependent Pulmonary Blood Flow Stent or BT shunt? Single ventricle tract repair LPA stenosis
PA & IVS at birth
Duct Dependent Pulmonary Blood Flow Stent or BT shunt? Single ventricle tract repair
PA & IVS at birth
Duct Dependent Pulmonary Blood Flow Stent or BT shunt? Single ventricle tract repair LAO + C
LPA stenosis
AP
PA & IVS at birth
Duct Dependent Pulmonary Blood Flow Stent or BT shunt? Single ventricle tract repair
PA & IVS at 6 month Pre-Glenn
Duct Dependent Pulmonary Blood Flow Stent or BT shunt?
Case 4 SV
Duct Dependent Pulmonary Blood Flow Stent or BT shunt? Single ventricle tract repair
Not profiled
PA & IVS at birth
Duct Dependent Pulmonary Blood Flow Stent or BT shunt? Single ventricle tract repair
PA & IVS at birth
Duct Dependent Pulmonary Blood Flow Stent or BT shunt? Single ventricle tract repair PDA shorten
PA & IVS at birth
Duct Dependent Pulmonary Blood Flow Stent or BT shunt? Single ventricle tract repair
PA & IVS at 5months
Duct Dependent Pulmonary Blood Flow Stent or BT shunt? Single ventricle tract repair
PA & IVS at 3 yrs
Duct Dependent Pulmonary Blood Flow Stent or BT shunt?
Case 1 BV
Duct Dependent Pulmonary Blood Flow Stent or BT shunt? Biventricular tract repair
d-TGA, VSD, PS & SubPS at birth 1
Duct Dependent Pulmonary Blood Flow Stent or BT shunt? Biventricular tract repair
d-TGA, VSD, PS & SubPS at birth 1
Duct Dependent Pulmonary Blood Flow Stent or BT shunt? Biventricular tract repair
d-TGA, VSD, PS & SubPS at 6 months
Duct Dependent Pulmonary Blood Flow Stent or BT shunt? Biventricular tract repair
d-TGA, VSD, PS & SubPS at 3 years follow up
Duct Dependent Pulmonary Blood Flow Stent or BT shunt? Biventricular tract repair
d-TGA, VSD, PS & SubPS at 3 years follow up
Duct Dependent Pulmonary Blood Flow Stent or BT shunt?
Case 2 BV
Duct Dependent Pulmonary Blood Flow Stent or BT shunt? Biventricular tract repair
PDA stent
8 months, TOF (isolated LPA from
LPA unifoc & CR in Jan 2007
6weeks old , TOF (isolated LPA from PDA)
Duct Dependent Pulmonary Blood Flow Stent or BT shunt? Biventricular tract repair
Complete Repair
11 months, TOF (isolated LPA from PDA)
LPA unifoc & CR
In Oct 08 (22 months) had Balloon angioplasty
Duct Dependent Pulmonary Blood Flow Stent or BT shunt? Biventricular tract repair
Complete Repair
No further intervension
LPA unifoc & CR
In Oct 12 ( 6 yrs later) had LPA stent will need further angioplasty
Duct Dependent Pulmonary Blood Flow Stent or BT shunt? Biventricular tract repair
Case 3 BV
Duct Dependent Pulmonary Blood Flow Stent or BT shunt? Biventricular tract repair
2 weeks with TVD & Functional Pulmonary Atresia on PGE
Duct Dependent Pulmonary Blood Flow Stent or BT shunt? Biventricular tract repair
PDA was not covered completely
2 weeks with TVD & Functional Pulmonary Atresia on PGE
Duct Dependent Pulmonary Blood Flow Stent or BT shunt? Biventricular tract repair
6 weeks later ( no PDA shunt) , well with still severe TR waiting
Duct Dependent Pulmonary Blood Flow Stent or BT shunt? Biventricular tract repair
Case 4 BV
Duct Dependent Pulmonary Blood Flow Stent or BT shunt? Biventricular tract repair Long PDA with PA’s branch stenosis
2 weeks old PA/VSD , weight 2.8 kg
Duct Dependent Pulmonary Blood Flow Stent or BT shunt? Biventricular tract repair Long PDA with PA’s branch stenosis
2 weeks old PA/VSD , weight 2.8 kg
Duct Dependent Pulmonary Blood Flow Stent or BT shunt?
Case 5 BV
Faisal
PA/IVS moderately Hypoplastic RV
At birth blue Sat was 60-70%, echo done, referred , came at 5 days on Abx , suspected septic, ? NEC
Faisal
PA/IVS moderately Hypoplastic RV
Before procedure at 20 days
Faisal
PA/IVS moderately Hypoplastic RV
12hrs after procedure RFA & BVP + PDA stenting
Faisal
PA/IVS moderately Hypoplastic RV
3 months admitted with febrile illness
Faisal
PA/IVS moderately Hypoplastic RV
7 months at home
Faisal
PA/IVS moderately Hypoplastic RV
2.5 yrs. at hospital for small ASD-II closure (R→L)
Faisal
PA/IVS moderately Hypoplastic RV
2.5 yrs. at hospital for small ASD-II closure (R→L)
Faisal
PA/IVS moderately Hypoplastic RV
2.5 yrs. at home after ASD device closure
PDA stenting: Daydream
B-T shunt: Nightmare
The Choice is yours