Retrospektive Analyse und Vergleich zwischen interventionellem Ductus arteriosus Stenting und des chirurgischen aortopulmonalen Shunts als erste Palliation bei Patienten mit pulmonaler Atresie und ventrikulärem Septumdefekt

Abstract

Background: Pulmonary atresia with ventricular septal defect (PA-VSD) is a complex congenital heart defect that requires staged palliation before definitive repair. Two primary palliative strategies—patent ductus arteriosus (PDA) stenting and aortopulmonary (AP) shunting—are commonly employed to maintain pulmonary blood flow. This study retrospectively compares outcomes between these two approaches. Methods: A retrospective analysis was conducted on 64 patients who underwent initial palliation with either PDA stenting (n=30) or AP shunting (n=34) between 1999 and 2019 at the Centre for Congenital Heart Disease (Kinderherzzentrum) Giessen. Outcomes were assessed across four stages: initial palliation (Stage 1), interstage period (Stage 2), complete surgical repair (Stage 3), and long-term follow-up (Stage 4). Primary endpoints included procedural success, complication rates, reintervention rates, and long-term survival. Results: Birth characteristics, including weight, length, and gestational age, were similar between groups. However, MAPCAs were more frequently observed in the AP shunt group (48.4% vs. 20%, p=0.020). At the time of initial palliation, the PDA stent group had significantly lower weight (p=0.029) and length (p=0.022). The hospital stay and ICU length were not significantly different between groups. Perioperative complications occurred in both groups but were slightly more frequent in the AP shunt cohort (53.3% vs. 43.3%, p=0.438). During the interstage period, complications were observed in 38.2% of the AP shunt group and 23.3% of the PDA stent group (p=0.199), though reintervention rates were comparable (p=0.683). Patients in the PDA stent group underwent complete repair significantly earlier (258.17 vs. 960.79 days, p=0.011). MAPCA unifocalization was more frequent in the AP shunt group (18.2% vs. 3.4%, p=0.109). The need for intraoperative LPA- or either RPA- or LPA-enlargement was higher in the PDA-Stent (65.5% vs. 29.4%, p=0.004 and 67.9 vs. 35.3, p= 0.011). Long-term follow-up showed no statistically significant difference in mortality, with one early postoperative death in the AP shunt group (p=0.352). The need for reintervention was slightly higher in the AP shunt group (81.8% vs. 62.1%, p=0.082), though not statistically significant. The type of reintervention differed, with PDA stent patients undergoing more catheter-based procedures and AP shunt patients requiring more surgical reinterventions. Conclusions: Both PDA stenting and AP shunting are viable palliative options for PA-VSD, with similar long-term survival outcomes. However, PDA stenting appears to facilitate earlier complete repair with fewer interstage complications. AP shunting remains a reliable approach, particularly in patients with MAPCAs. And seems to reduce the burden of PA stenosis requiring enlargement intraoperatively. Future studies with larger cohorts and longer follow-up as well as randomized clinical trials are necessary to refine treatment algorithms further.