Surgical Shunt Versus Transcatheter Ductal Stent For Neonates with Ductal-Dependent Pulmonary Blood Flow: Is One Better?– Define Better
Susan Nicolson, Lindsey Loveland Baptist, James DiNardo, Viviane Nasr
Before reading today’s PAAD, I’d like to wish our members a happy Ganesh Chaturthi, a holdiay also known as Vinayak Chaturthi or Ganeshotsav. It is a Hindu festival commemorating the birth of the Hindu god Ganesha. Myron Yaster MD
Original article
Valencia E, Staffa SJ, Kuntz MT, Zaleski KL, Kaza AK, Maschietto N, Nasr VG. Transcatheter Ductal Stents Versus Surgical Systemic-Pulmonary Artery Shunts in Neonates With Congenital Heart Disease With Ductal-Dependent Pulmonary Blood Flow: Trends and Associated Outcomes From the Pediatric Health Information System Database. J Am Heart Assoc. 2023 Sep 5;12(17):e030528. doi: 10.1161/JAHA.123.030528. Epub 2023 Aug 17. PMID: 37589149.
Surgical systemic-to-pulmonary artery shunts (classic and modified Blalock-Thomas-Taussig, Waterston) have long been the standard approach to establish stable pulmonary blood flow (PBF) in neonates with congenital heart disease (CHD) with ductal-dependent PBF. Despite decades of experience, surgical shunts continue to present a high risk of morbidity and mortality with patient related factors including: preoperative shock and/or ventilatory support, weight < 3kg anatomic diagnosis, use of sternotomy and cardiopulmonary bypass contributing significantly.(1) Recently, transcatheter ductal stents have become increasing utilized as an alternative, less invasive intervention. Using the Pediatric Heath Information System (PHIS) data, Valencia et al.(2) retrospectively analyzed neonates (< 30 days) who underwent surgical shunt or ductal stent placement between January 2016 and December 2021 to characterize current trends in utilization and compare associated outcomes and resource utilization. PHIS is an administrative and billing database containing information from patient encounters from 50 not-for-profit pediatric hospitals affiliated with the Children’s Hospital Association that differ in volume and experience. The primary outcome was hospital length of stay (LOS), subcategorized into total and postintervention LOS. Secondary outcomes were rate of reintervention within 30 days, 3 and 6 months and total adjusted cost for the index hospitalization. A reintervention was defined as a procedure subsequent to the index palliation that was performed to address the ductal stent, surgical shunt or pulmonary arteries. Additional outcomes of interest included in-hospital mortality, frequency and duration of postintervention mechanical ventilation, and 30-day readmission.
Multivariable adjusted analyses for continuous outcomes were performed using the inverse probability of treatment weighing (IPTW) by the propensity score in order to compare the 2 treatments after controlling for baseline confounders. IPTW was implemented rather than traditional propensity score matching (PSM) to adjust for clinically relevant baseline confounding in a multivariable framework. Unlike PSM, which eliminates unmatched subjects, IPTW retains the entire subject cohort for matching and analysis which is particularly important if there are limitations in terms of sample size.
Of the 936 patients included from 45 hospitals, overall 65.2% underwent surgical shunt over the 6-year period. There was a 3-fold increase (19% to 53%) in the frequency of transcatheter ductal stenting from 2016 to 2021 and ductal stenting became the dominant palliative technique by 2021 (P< 0.001, figure 1). There was substantial interinstitutional variation of the proportion of cases managed with the two techniques. 14.9% of the centers did not perform any transcatheter ductal stents during the study period.
A greater proportion of patients who underwent ductal stenting were premature (18.4% vs 12.3%). Shunted neonates were more likely to have comorbid GI, renal, urologic and technology-dependent conditions. The shunt cohort had greater incidence of peri-intervention acute morbidities including renal insufficiency (17.1% vs 5.5%) and need for ECMO (9.5% vs 1.2%). Shunted neonates had a longer postintervention duration of mechanical ventilation (5 vs 2 days).
There was no significant difference in the risk of in hospital mortality for the surgical group compared to the transcatheter group (5.9% vs 4.3%). There was no difference in the 30-day readmission rate according to intervention type (surgical 22.6% vs transcatheter 25.8%).
Multivariate analysis demonstrated both a significantly longer hospital LOS for neonates who had a surgical intervention with an adjusted difference in medians (surgical -transcatheter) of 13 days. Similarly, the surgical group had a longer postintervention LOS with an adjusted difference in medians of 11 days. There was no difference in the incidence in the risk of reintervention at 30 days, but the ductal stent cohort had a greater incidence of reintervention at both 3 and 6 months. The majority of the reinterventions in the ductal stent group were transcatheter whereas those in the surgical group were surgical.
The median overall cost associated with surgical shunts are 50% greater than those associated with transcatheter stents for the index hospitalization. This is consistent with other studies finding that increased LOS for neonatal procedures results in increased cost.
Ductal stenting has become an increasing utilized approach to secure pulmonary blood flow in neonates with ductal-dependent PBF in the US. Ductal stenting is associated with decreased hospital and postintervention LOS and reduced cost for the index hospitalization but with a greater reintervention risk than surgical shunting. The lesser morbidity burden combined with the decreased cost suggests transcatheter stenting may offer greater value, at least for the index hospitalization. Prolonged LOS has been identified as an independent risk factor for mortality and long-term morbidity in neonates following cardiac surgery and has been linked to neurodevelopmental impairments.(3)
The authors chose the PHIS data to examine how a variety of hospitals replaced ductal-dependent PBF with a secure source of PBF in neonates with the full spectrum of cardiac lesions. However, this data source lacks the granularity to answer such important questions as: is one technique better than the other for certain anatomic subpopulations, which technique results in more symmetric growth of the branch pulmonary arteries, which patients are at risk for reintervention, which patients require cardiopulmonary bypass for shunt placement and do reinterventions performed during subsequent admissions negate the economic benefit of transcatheter stenting when summated with the index admission.
PS from Myron: As many of you are acutely aware, there is a national critical shortage of pediatric cardiac anesthesiologists. In your institution would only the cardiac team provide anesthesia for a transcatheter ductal stent performed in the cath lab or could any pediatric anesthesiologist do it? Send your responses to Myron who will post in a Friday Reader response.
References:
1. The Society of Thoracic Surgeons. Congenital Heart Surgery Database, 2023.
2. Valencia E, Staffa SJ, Kuntz MT, Zaleski KL, Kaza AK, Maschietto N, Nasr VG. Transcatheter Ductal Stents Versus Surgical Systemic-Pulmonary Artery Shunts in Neonates With Congenital Heart Disease With Ductal-Dependent Pulmonary Blood Flow: Trends and Associated Outcomes From the Pediatric Health Information System Database. J Am Heart Assoc 2023;12:e030528.
3. Mori M, McCracken C, Maher K, Kogon B, Mahle W, Kanter K, Alsoufi B. Outcomes of neonates requiring prolonged stay in the intensive care unit after surgical repair of congenital heart disease. J Thorac Cardiovasc Surg 2016;152:720-7.e1.