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. 2024 Nov 29:23:235-244.
doi: 10.1016/j.xjon.2024.11.011. eCollection 2025 Feb.

Surgical removal of pulmonary flow restrictors in children with congenital heart disease: What the outcomes reveal

Raymond N Haddad  1 , Jamie Bentham  2 , Carlos Pardo  3 , Rasha Alloush  4 , Mahmoud Al Soufi  4 , Osama Jaber  5 , Mohamed Kasem  4 , Issam El Rassi  6
Affiliations

Surgical removal of pulmonary flow restrictors in children with congenital heart disease: What the outcomes reveal

Raymond N Haddad et al. JTCVS Open. .

Abstract

Objective: Pulmonary flow restrictors (PFRs) are interesting devices, but their surgical removal outcomes are poorly understood.

Methods: Retrospective review of clinical data from children with bilateral PFRs who underwent device removal during follow-up surgery.

Results: Thirty-four PFRs were explanted from 17 patients (41.2% boys) at a median of 2 months (interquartile range [IQR], 1.2-5.2 months) postimplantation, with a median patient age of 2.5 months (IQR, 1.6-5.8 months). One patient experienced life-threatening bilateral pulmonary artery (PA) aneurysms 2 months after PFR implantation, necessitating urgent surgery. Two PFRs were found migrated across the left PA's upper lobe branch origin. Twenty-six were removed intact, 1 in 2 fragments, and 7 piecemeal. No thrombus was noted. Neoendothelium was observed on 11 PFRs. Seven PFRs caused endothelial damage, requiring sharp and blunt dissection for removal. Six right and 4 left PA arteriotomies were patched. Hegar dilators, with median sizes of 7 mm (IQR, 6.8-8.3 mm) for right PA and 7 mm (IQR, 7-8 mm) for left PA, confirmed branch patency. At a median follow-up of 14.8 months (IQR, 10.2-18.3 months), echocardiographic maximum velocities in 13 biventricular patients and 2 awaiting future biventricular repair were 1.5 m/second (IQR, 1.4-1.7 m/second) for the left PA and 1.6 m/second (IQR, 1.4-1.7 m/second) for the right PA. One patient with deferred Norwood had normal PAs and well-positioned PFRs on prestage-II catheterization. A patient who underwent stage-II Norwood 3.2 months post-PFR implantation died from sepsis 1 month later, but post-Glenn angiogram revealed no stenosis.

Conclusions: PFR removal is safe and effective. Complications are manageable, with no PA stenosis observed.

Keywords: congenital heart disease; microvascular plug; pulmonary artery band; pulmonary flow restrictor; stage-I Norwood procedure.

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Conflict of interest statement

The authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest.

Figures

None
Surgical extraction of pulmonary flow restrictors.
Figure 1
Figure 1
A, Extraction of pulmonary flow restrictors (PFRs) through main pulmonary artery (PA) incision (dashed line). B, Retraction of left and right PAs for better exposure. C, Distal migration of the device in the right PA. D, An incision on the right PA (dashed line) for improved PFR extraction. E, Distal device migration in the left PA. F, Anterior arteriotomy on the right PA (dashed line) for enhanced PFR exposure and extraction. G, Closure: main PA incision is closed directly, branch PAs are repaired with a pericardial patch. RPA, Right pulmonary artery; LPA, left pulmonary artery.
Figure 2
Figure 2
Pulmonary angiograms. A, Before pulmonary flow restrictors (PFRs) implantation. B, After PFR implantation. C, Post-Glenn anastomosis following PFR removal.
See this image and copyright information in PMC

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