Editorial Comment Is Bigger Always Better? Pulmonary Artery Growth After Arterial Duct Stent: Univentricular Palliation, Bridge to Complete Repair and Definitive Therapy Victor Lucas * MD, FSCAI Section Head, Pediatric Cardiology, Ochsner Clinic Foundation, New Orleans, Louisiana In this edition of the Journal, Dr. Giuseppe Santoro and colleagues present their carefully cataloged obser- vations regarding pulmonary artery growth after stenting of the arterial duct in newborns with ductus dependent pulmonary blood flow. Ductus stenting was chosen in 47 consecutive patients as an alternative to surgical modified Blalock-Taussig shunt placement. 7/ 47 patients were entirely dependent on the ductus for pulmonary blood flow. Outstanding results with a ret- rograde arterial approach utilizing coronary equipment were obtained with no procedural failures, abrupt ductus closure, or unanticipated reintervention reported. In a subset, gradual and progressive hypoxemia occurred as expected. If these results can be repeated, ductus stenting likely will be a very significant advance in caring for ill newborns with ductus dependent pulmonary blood flow and may eventually largely relegate surgical aor- topulmonary shunting to history. The authors empha- sized the use of low profile coronary stents with favorable longitudinal flexibility characteristics and the complete stent coverage of the ductus as keys to suc- cess. They demonstrated very favorable pulmonary artery growth characteristics (favorably disproportionate to somatic growth) including the complete absence of significantly asymmetric branch pulmonary artery growth. Several important questions remain unanswered. What is the most appropriate antiplatelet therapy for the stented ductus? Which is the best bare-metal stent? Is there any role for drug-eluting stents to minimize progressive in-stent stenosis or is the risk of abrupt closure increased in the ductus as in coronary arteries? Is ductus stenting really as safe as surgical shunt when the sole source of pulmonary blood flow is the ductus? Is it more safe then surgery? Perhaps most importantly, what is the most appropriate stented ductus size, particularly in the baby with a univentricular cardiac defect requiring enough pulmonary blood flow to promote pulmonary arterial growth, but at low enough pressure to preserve pulmonary arterial capacitance and resistance suffi- ciently to allow a successful Fontan-type palliation? I suspect that the answer would be that bigger is better so long as the pulmonary vascular resistance remains low. The authors are to be commended on their efforts and for the outstanding results obtained. I look forward to hearing more on ductus stenting in the future. Conflict of interest: No conflict of interest. *Correspondence to: Victor Lucas, 1315 Jefferson Hwy, New Orle- ans, LA 70121. E-mail: [email protected] Received 7 October 2009; Revision accepted 8 October 2009 DOI 10.1002/ccd.22341 Published online 25 November 2009 in Wiley InterScience (www. interscience.wiley.com). ' 2009 Wiley-Liss, Inc. Catheterization and Cardiovascular Interventions 74:1077 (2009)

Is bigger always better? Pulmonary artery growth after arterial duct stent: Univentricular palliation, bridge to complete repair and definitive therapy

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Page 1: Is bigger always better? Pulmonary artery growth after arterial duct stent: Univentricular palliation, bridge to complete repair and definitive therapy

Editorial Comment

Is Bigger Always Better?Pulmonary Artery Growth AfterArterial Duct Stent:Univentricular Palliation, Bridgeto Complete Repair andDefinitive Therapy

Victor Lucas* MD, FSCAI

Section Head, Pediatric Cardiology, Ochsner ClinicFoundation, New Orleans, Louisiana

In this edition of the Journal, Dr. Giuseppe Santoro

and colleagues present their carefully cataloged obser-

vations regarding pulmonary artery growth after stent-

ing of the arterial duct in newborns with ductus de-

pendent pulmonary blood flow. Ductus stenting was

chosen in 47 consecutive patients as an alternative to

surgical modified Blalock-Taussig shunt placement. 7/

47 patients were entirely dependent on the ductus for

pulmonary blood flow. Outstanding results with a ret-

rograde arterial approach utilizing coronary equipment

were obtained with no procedural failures, abrupt duc-

tus closure, or unanticipated reintervention reported. In

a subset, gradual and progressive hypoxemia occurred

as expected.If these results can be repeated, ductus stenting

likely will be a very significant advance in caring forill newborns with ductus dependent pulmonary blood

flow and may eventually largely relegate surgical aor-topulmonary shunting to history. The authors empha-sized the use of low profile coronary stents with favor-able longitudinal flexibility characteristics and thecomplete stent coverage of the ductus as keys to suc-cess. They demonstrated very favorable pulmonary ar-tery growth characteristics (favorably disproportionateto somatic growth) including the complete absenceof significantly asymmetric branch pulmonary arterygrowth.Several important questions remain unanswered.

What is the most appropriate antiplatelet therapy forthe stented ductus? Which is the best bare-metal stent?Is there any role for drug-eluting stents to minimizeprogressive in-stent stenosis or is the risk of abruptclosure increased in the ductus as in coronary arteries?Is ductus stenting really as safe as surgical shunt whenthe sole source of pulmonary blood flow is the ductus?Is it more safe then surgery?Perhaps most importantly, what is the most appro-

priate stented ductus size, particularly in the babywith a univentricular cardiac defect requiring enoughpulmonary blood flow to promote pulmonary arterialgrowth, but at low enough pressure to preserve pul-monary arterial capacitance and resistance suffi-ciently to allow a successful Fontan-type palliation? Isuspect that the answer would be that bigger is betterso long as the pulmonary vascular resistance remainslow. The authors are to be commended on theirefforts and for the outstanding results obtained. Ilook forward to hearing more on ductus stenting inthe future.

Conflict of interest: No conflict of interest.

*Correspondence to: Victor Lucas, 1315 Jefferson Hwy, New Orle-

ans, LA 70121. E-mail: [email protected]

Received 7 October 2009; Revision accepted 8 October 2009

DOI 10.1002/ccd.22341

Published online 25 November 2009 in Wiley InterScience (www.

interscience.wiley.com).

' 2009 Wiley-Liss, Inc.

Catheterization and Cardiovascular Interventions 74:1077 (2009)