Clinical results of combined palliative procedures for cyanotic congenital heart defects with intractable hypoplasia of pulmonary arteries
Authors: FAN Xiang-ming , ZHU Yao-bin , SU Jun-wu , ZHANG Jing , LI Zhi-qiang , XU Yao-qiang , LI Xiao-feng , LIU Ying-long 
Published: January 2024

Background
Congenital heart defects with intractable hypoplasia of the pulmonary arteries without intercourse or with intercourse stenosis is unsuitable for surgical correction or regular palliative procedures. We reported our experience with combined palliative procedures for congenital heart defects with intractable hypoplasia pulmonary arteries.

Methods
From 2001 to 2012, a total of 41 patients with cyanotic congenital heart defects and intractable hypoplasia of the pulmonary arteries underwent surgical procedures. From among them, 31 patients had pulmonary atresia with ventricular septal defect (VSD) and the other 10 cases had complicated congenital heart defects with pulmonary stenosis. Different kinds of palliative procedures were performed according to the morphology of the right and left pulmonary arteries in every patient. If the pulmonary artery was well developed, a Glenn procedure was performed. A modified Blalock-Taussig shunt or modified Waterston shunt was performed if pulmonary arteries were hypoplastic. If the pulmonary arteries were severely hypoplastic, a Melbourne shunt was performed. Systemic pulmonary artery shunts were performed bilaterally in 25 cases. A systemic-pulmonary shunt was performed on one side and a Glenn procedure was performed contralaterally in 16 cases. Major aortopulmonary collateral arteries were unifocalized in six cases, ligated in two cases and interventionally embolized in two cases. There was one early death because of cardiac arrest and the hospital mortality was 2.4%.

Results
Five patients suffered from postoperative low cardiac output syndrome, three had perfusion of the lungs, and two pulmonary infections. Systemic pulmonary shunts were repeated after the original operation in three cases due to the occlusion of conduits. The mean follow-up time was 25 months. The pre- and the post-operation left pulmonary indices were (8.13±3.68) vs. (14.9±6.21) mm2/m2. The pre- and post-operation right pulmonary indices were (12.7±8.13) vs. (17.7±7.78) mm2/m2. The pre- and post-operational pulmonary indices were (20.87±9.43) vs. (32.6±11.7) mm2/m2. They were all significantly increased (P <0.001). The diameter of the pulmonary artery increased after the modified Blalock-Taussig shunt ((5.51±0.94) mm2/m2 pre-operation vs. (7.01±1.97) mm2/m2 post-operation), the modified Waterston shunt ((5.70±3.96) mm2/m2 pre-operation vs. (9.17±3.62) mm2/m2 post-operation) and the Melbourne shunt ((2.17±0.41) mm2/m2 pre-operation vs. (7.35±2.49) mm2/m2 post-operation) (all P <0.05). Bilateral pulmonary arteries developed well as compared to their pre-operation development. Hemoglobin decreased from (194±27) to (174±24) g/L (P <0.05) and peripheral oxygen saturation increased from (65±11)% to (84±6)% (P <0.001). During the follow-up of 27 to 49 months, ultimate complete repair was performed in four cases and one patient underwent a Glenn procedure.

Conclusions
The procedures should be considered on a case to case basis in patients having hypoplasia of the pulmonary arteries with cyanotic congenital heart defects. Combined palliative operations could be an adequate strategic treatment.