Impact of Treatment Strategy on Outcomes in Isolated Pulmonary Artery of Ductal Origin.

2021

2021 Jan 04

1432-1971

<p>Isolated pulmonary artery (PA) of ductal origin (IPADO) is a rare cardiac defect which requires surgical repair, with or without preceding palliation. We sought to determine the impact of treatment strategy on outcomes. Retrospective study of consecutive patients with IPADO that underwent staged or primary repair from 1/05 to 9/16 at 6 Congenital Cardiac Research Collaborative centers. Patients with single ventricle physiology, major aortopulmonary collaterals, or bilateral IPADO were excluded. Primary outcome was isolated PA z-score at late follow-up. Secondary outcomes included PA symmetry index (isolated:confluent PA diameter) and reintervention burden. Propensity score adjustment was used to account for baseline differences. Of 60 patients in the study cohort, 26 (43%) underwent staged and 34 (57%) primary repair. The staged and primary repair groups differed in weight at diagnosis and presence of other heart disease but not in baseline PA dimensions. Staged patients underwent ductal stent (n = 16) or surgical shunt (n = 10) placement followed by repair at 210 vs. 21 days in the primary repair group (p &lt; 0.001). At median follow-up of 4.5 years post-repair, after adjustment, isolated PA z-score (- 0.74 [- 1.75, - 0.26] vs. - 1.95 [- 2.91, - 1.59], p = 0.012) and PA symmetry index (0.81 [0.49, 1.0] vs. 0.55 [0.48, 0.69], p = 0.042) significantly favored the staged repair group. Freedom from PA reintervention was not different between groups (adjusted HR 0.78 [0.41, 1.48]; p = 0.445). A staged approach to repair of IPADO is associated with superior isolated PA size and symmetry at late follow-up. Consideration should be given to initial palliation in IPADO patients, when feasible.</p>

10.1007/s00246-020-02511-y

Pediatr Cardiol

33394118

Differences in Cost of Care by Palliation Strategy for Infants With Ductal-Dependent Pulmonary Blood Flow.

2019

e007232

2019 Apr

1941-7632

<p><strong>BACKGROUND: </strong>In infants with ductal-dependent pulmonary blood flow, initial palliation with patent ductus arteriosus (PDA) stent or modified Blalock-Taussig (BT) shunt have comparable mortality but discrepant length of stay, procedural complication rates and reintervention burdens, which may influence cost. The relative economic impact of these palliation strategies is unknown.</p>

<p><strong>METHODS AND RESULTS: </strong>Retrospective study of infants with ductal-dependent pulmonary blood flow palliated with PDA stent (n=104) or BT shunt (n=251) from 2008 to 2015 at 4 centers of the Congenital Catheterization Research Collaborative. Inflation-adjusted inpatient hospital costs were calculated for first year of life using Pediatric Health Information System data. Costs derived from outpatient catheterizations not in Pediatric Health Information System were imputed. Costs were compared using propensity score-adjusted multivariable models, to account for baseline differences between groups. After propensity score adjustment, first year of life costs were significantly lower in PDA stent ($215 825 [190 644-244 333]) than BT shunt ($249 855 [230 693-270 609]) patients ( P=0.05). After addition of imputed costs, first year of life costs were not significantly different between PDA stent ($226 403 [200 274-255 941]) and BT shunt ($252 072 [232 955-272 759]) groups ( P=0.15). Patient characteristics associated with higher costs included: younger gestational age, genetic syndrome, noncardiac diagnoses, procedural complications, extracorporeal membrane oxygenation, duration of ventilation, intensive care unit and hospital length of stay and reintervention ( P≤0.02 for all).</p>

<p><strong>CONCLUSIONS: </strong>In this first multicenter comparative cost study of PDA stent or BT shunt as palliation for infants with ductal-dependent pulmonary blood flow, adjusted for baseline differences, PDA stent was associated with lower to equivalent costs over the first year of life. Combined with previous evidence suggesting clinical noninferiority, these findings suggest that PDA stent provides competitive health care value.</p>

10.1161/CIRCINTERVENTIONS.118.007232

Circ Cardiovasc Interv

30998390

A Comparison Between Patent Ductus Arteriosus Stent and Modified Blalock-Taussig Shunt as Palliation for Infants with Ductal-Dependent Pulmonary Blood Flow: Insights From the Congenital Catheterization Research Collaborative.

2018

589-601

2018 Feb 6

1524-4539

<p>Background -Infants with ductal-dependent pulmonary blood flow may undergo palliation with either a patent ductus arteriosus (PDA) stent or modified Blalock-Taussig (BT) shunt. A balanced multi-center comparison of these two approaches is lacking. Methods -Infants with ductal-dependent pulmonary blood flow, palliated with either PDA stent or BT shunt from 1/08 to 11/15, were reviewed from the four member centers of the Congenital Catheterization Research Collaborative. Outcomes were compared using propensity score adjustment to account for baseline differences between groups. Results -106 PDA stent and 251 BT shunt patients were included. The groups differed in underlying anatomy (expected two-ventricle circulation in 60% of PDA stents v. 45% of BT shunts, p=0.001), and presence of antegrade pulmonary blood flow (61% of PDA stents v. 38% of BT shunts, p&lt;0.001). After propensity score adjustment, there was no difference in the hazard of the primary composite outcome of death or unplanned reintervention to treat cyanosis [HR=0.8 (95% CI: 0.52 - 1.23), p=0.31]. Other reinterventions were more common in the PDA stent group [HR=29.8 (95% CI: 9.8 - 91.1, p&lt;0.001]. However, the PDA stent group had a lower adjusted ICU length of stay [5.3 (95% CI 4.2 - 6.7) v. 9.19 (95% CI 7.9 - 10.6) days, p&lt;0.001], a lower risk of diuretic use at discharge [OR=0.4 (95% CI: 0.25 - 0.64), p&lt;0.001] and procedural complications [OR=0.4 (95% CI: 0.2 - 0.77), p=0.006], and larger [152 (95% CI: 132 - 176) v. 125 (95% CI: 113 - 138) mm(2)/m(2), p=0.029] and more symmetric [symmetry index 0.84 (95% CI: 0.8 - 0.89) v. 0.77 (95% CI: 0.75 - 0.8), p=0.008] pulmonary arteries at the time of subsequent surgical repair or last follow-up. Conclusions -In this multi-center comparison of palliative PDA stent and BT shunt for infants with ductal-dependent pulmonary blood flow, adjusted for differences in patient factors, there was no difference in the primary endpoint, death or unplanned reintervention to treat cyanosis. However, other markers of morbidity and pulmonary artery size favored the PDA stent group, supporting PDA stent as a reasonable alternative to BT shunt in select patients.</p>

10.1161/CIRCULATIONAHA.117.029987

Circulation

29042354