1. Intern 柳孟鵑 Supervisor: VS 謝旻玲
Intern seminar
Intern 柳孟鵑
Supervisor: VS 謝旻玲

2. Identifying Information
Name: 李O霈之女
Gender: Female
Birthday :
Identifying Information
Chief complaint
Tachypnea and desaturation after birth

3. Present illness 30 years old mother GA39+4 wks NSD
No known systemic diseases
Uneventful prenatal and perinatal history
GA39+4 wks NSD
BBW 2280 g
Desaturation 6 hours after birth (SpO2 82% with O2 3L/min )
Tachypnea , nasal flaring, and suprasternal/subcostal retraction
 Transfer to our hospital
This is a just born female baby, (G1P1, GA39+4 weeks, by NSD, Apar score8->9), without any known systemic or congenital diseases. Her BBW was 2280 gm(<5 th percentage).She was born in 陳澤彥's clinical and the prenatal care was uneventful. There was no maternal GDM, hypertension, preeclampsia and other systemic diseases. They also denied GBS colonization, PROM and infectious epis
According to the family and the transfer note, SpO2 was around 80% after delivery, but no cyanosis of skin was noted. The saturation returned to 90% after O2 3 L/min was given. At there, due to SGA, finger sugar showed above 50 after oral dextrose 15ml. Therefore, she was transferred to our hospital for further evaluation. At our ward, tachypnea and desaturation episode was noted (SpO % under room air). Nasal flaring and intercostal retraction were also noted. There was no fever, nausea/vomiting, lethargy, anorexia, URI symptoms, abdominal bloating, diarrhea, decreased urine output, abnormal stool or urine color, skin rash, ecchymosis or petechiae, peripheral edematous change, juandice. There was no specific contact and medication history.odes.
This female infant was born at GA 39+4 weeks via NSD, BBW 2280g, Apgar score 8→9. She is an SGA baby. She was born at 陳澤彥's clinical and the prenatal care was uneventful. Desaturation was noted 6 hours after birth (around 8pm on 11/21). The SpO2 was 88% under room air and there was also nasal flaring, tachypnea and suprasternal/subcostal retraction. Her saturation was improved to 93-95% under O2 3L/min use. Due to respiratory distress, she was referred to our hospital for furthur evaluation and management. After admission, septic workup was done and empiric antibiotics were given. Her saturation was around 84-88% under room air and improved above 95% under O2 use. Chest x ray showed cardiomegaly and increased infiltration over right lung field. Difference between upper/lower limbs saturation was noted. Cardiac echo revealed suspicious coarctation of aorta. Tachypnea was still noted after admission, and CO2 retention was noted. Therefore, she was transferred to ICU for more intensive care

4. Family history

5. Physical examination
Vital Signs (11/21 22:00) : T: 36.5°C P: 134/min R: 66/min BP: 69/41mmHg
HR: Newborn
RR: Newborn30-50
1-12 months :
SpO2 82 % after O2 3L/min

6. Physical examination
[HEENT] Head: no swelling, soft and open ant. fontanelle Conjunctiva: not pale
Lip: no cyanosis
Nose: normal nostrils, nasal flare
Neck: no torticollis, no palpable mass
[Chest]
Intercostal retraction No crackle or wheezing
[Heart] Grade II pan-systolic murmur over left lower sternal border
HR: Newborn
RR: Newborn30-50
1-12 months :
SpO2 82 % after O2 3L/min

7. 74/52 mmHg
83/39 mmHg
89/60 mmHg
73/41 mmHg
97%
98%
83%
84% 7

8. Cardiothoracic ratio : 55.9%
Chest AP view
Cardiothoracic ratio : 55.9%
Ct ratio
Film of shows:
> Suspicious for right sided aortic arch.
> Coarsening of bilateral peribronchovascular bundles favoring inflammatory process.
> Both CP angles are sharp.
蔡依珊醫師-放診專 682 --

9. Cardiac echo
Right PDA
Coarctation of aorta, VSD, inter-atrial shunt, PDA, non-confluent RPA and LPA, LPA from left PDA
1)Situs solitus, levocardia
2)RA, RV chamber dilation
3)An inter-atrial left to right shunting, size: 0.428cm
4)Posterior deviation of interventricular septum in systolic phase without LVOT obstruction
5)Good LV systolic function with LVEF: 57.4%
6)Dilated MPA and small right PA, non-confluence of RPA and LPA
7)Large right patent ductus arteriosus with R to L shunt, size: 0.563cm
8)LPA from left PDA arising from aortic arch
9)An interventricular septal defect, size: 0.272c, bidirectional shunt
10)Severe coarctation of aorta, nearly total occclusion, right arch

10. Coarctation of aorta, right arch
Coarctation of aorta, VSD, inter-atrial shunt, PDA, non-confluent RPA and LPA, LPA from left PDA
1)Situs solitus, levocardia
2)RA, RV chamber dilation
3)An inter-atrial left to right shunting, size: 0.428cm
4)Posterior deviation of interventricular septum in systolic phase without LVOT obstruction
5)Good LV systolic function with LVEF: 57.4%
6)Dilated MPA and small right PA, non-confluence of RPA and LPA
7)Large right patent ductus arteriosus with R to L shunt, size: 0.563cm
8)LPA from left PDA arising from aortic arch
9)An interventricular septal defect, size: 0.272c, bidirectional shunt
10)Severe coarctation of aorta, nearly total occclusion, right arch

11. LPA from left PDA
Small RPA
Non-confluent RPA and LPA

12. VSD
Coarctation of aorta, VSD, inter-atrial shunt, PDA, non-confluent RPA and LPA, LPA from left PDA
1)Situs solitus, levocardia
2)RA, RV chamber dilation
3)An inter-atrial left to right shunting, size: 0.428cm
4)Posterior deviation of interventricular septum in systolic phase without LVOT obstruction
5)Good LV systolic function with LVEF: 57.4%
6)Dilated MPA and small right PA, non-confluence of RPA and LPA
7)Large right patent ductus arteriosus with R to L shunt, size: 0.563cm
8)LPA from left PDA arising from aortic arch
9)An interventricular septal defect, size: 0.272c, bidirectional shunt
10)Severe coarctation of aorta, nearly total occclusion, right arch

13. Heart CTA PDA MPA PDA Lt. Subclavian a. Lt. Subclavian a.
Clinical information:
■1.Respiratory distress ■2.Small for gestational age ■3.Polycythemia
Heart CTA is performed on the dual-source CT scanner with contrast enhancement and presented on the MIP and VRT in multiple projections.
1. HEART:
A. Intact interventricular septum.
B. Suspicious for interatrial spetum defect.
C. AV concordance and VA concordance
2. PULMONARY VASCULATURES:
A. Dilated MPA with patent ductus arteriosus, 4.2mm.
B. Suspicious for single right pulmonary artery with hypoplastic change.
C. The left pulmonary artery supplied from left subclavian artery.
- Relatively poor left lung pulmonary vasculature.
D. Venous return of the pulmonary veins are unremarkable but smaller PV are noted.
3. SYSTEMIC VASCULATURES:
A. Right-sided aortic arch.
B. Focal junctional stenosis at the isthmus portion of aorta, 1.6mm, consistent with aortic coarctation
C. Left carotid artery artery and LSA arising from left innominate artery with persistent patent left PDA conneting to left pulmonary artery.
4. Others: Bilateral basal lung subpleural atelctasis/consolidaiton.
IMP:
1. Aortic coarctation, 1.6mm.
2. Dilated RV with right PDA, 4.2mm.
- Suspicious for ASD
3. Single right pulmonary artery with hypoplastic change.
4. Right sided aortic arch with left innominate artery as the 1st branch
- Persistent patent left PDA conneting to left pulmonary artery
- Junctional stenosis between the left PDA and LPA
6. Bilateral basal lung subpleural atelctasis/consolidaiton.
7. Unremarkable trachea and main bronchi.
蔡依珊醫師-放診專 682 --

14. Catheterization on 12/01 Left pulmonary artery arising from
PDA
Descending aorta
Lt. pulmonary a
Lt. PDA
左邊無顯影
DIAGNOSIS:
1.Hypoplastic aortic isthmus with mild coarctation of aorta (no pressure gradient)
2.Large Patent ductus arteriosus (PDA)8 mm, tubular type post Amplatzer vascular pulg I (10 mm)
3.Anomalous left pulmonary artery arising from left side PDA post stent (4.0 mm x 8 mm) deployment
HEMODYNAMIC FINDINGS： The PA pressure was mildly elevated (48/42mmHg) and there was no pressure gradient from MPA to RV(48/42mmHg->44/25mmHg). The Ao pressure was 50/46mmHg. There was no significant pressure gradient from A-Ao to D-Ao.
ANGIOGRAPHIC FINDINGS： The A-aortogram showed a significant flow shunting from D-Ao to MPA, compatible with PDA. The PDA was tubular shape and the size measured was 8mm. After Amplatzer vascular plug 10mm was applied, we performed A-aortogram again. It showed no obvious residual shunt. We then advanced a 5Fr JR4 catheter to LPA through left side PDA. A OMEGA stent 4.0 mm x 8 mm / Boston was used to stent the PDA.　
PROCEDURE NOTES： We set up two routes from right femoral artery and left femoral vein via 4Fr sheath and shifted left femoral artery sheath to a 5 Fr sheath. A 4Fr Bermann catheter was used for right heart diagnostic catheterization and hemodynamic study. Transient balloon occlusion of PDA was done to test the hemodynamics results of PDA occlusion. There was no prssure gradient from A-AO to D-AO then. Therefore, a 4F multipurpose catheter was advanced through D-Ao to A-Ao for angiogram. The left femoral vein sheath was exchanged to a 6F sheath, we then advanced a 6Fr MP catheter through the PDA and applied an Amplatzer vascular Plug 10mm. A-AO angiogram was performed and showed no residual shunt. We then advanced a 5Fr JR 4 guiding catheter into the left side PDA and advanced to LPA via left femoral artery. A OMEGA stent 4.0 mm x 8 mm was applied. 　
王玠能-心專 S720
Left pulmonary artery arising from
left side PDA
post stenting (4.0 mm x 8 mm )
Right PDA: 8 mm, tubular
Amplatzer vascular pulg I (10 mm)

15. Post intervention Aspirin Clopidogrel Digoxin Furosemide IVD
Furosemide PO
Digoxin
,Aspirin 100mg/tab (Ropal) 就醫資訊 開立日 Order 開立者 住院,入院日:2016/11/21,出院日:2016/12/12科別:61一般小兒科,主治:王玠能 2016/12/1 QDPC 10mg,總量:10mg PO
Clopidogrel 75mg/tab (Plavix) 就醫資訊 開立日 Order 開立者 住院,入院日:2016/11/21,出院日:2016/12/12科別:61一般小兒科,主治:王玠能 2016/12/1 QDPC 0.50mg
,Furosemide inj 針_利尿 20mg/2mL/amp(Rasitol) 就醫資訊 開立日 Order 開立者 住院,入院日:2016/11/21,出院日:2016/12/12科別:61一般小兒科,主治:王玠能 2016/12/2 Q8H 2.40mg,總量:2.40mg IVD ,1日 魏昱仁 2016/12/2 Q8H 20mg,總量:20mg IVD ,7日 蔡瑋峻 2016/12/1 STAT 2.40mg,總量:2.40mg IVD
:389636,Furosemide oral sol 液劑 10mg/mL, 120mL/btl (Fumide) 就醫資訊 開立日 Order 開立者 住院,入院日:2016/11/21,出院日:2016/12/12科別:61一般小兒科,主治:王玠能 2016/12/6 BID 0.20mL,總量:0.20mL PO
Digoxin elixir 液劑 0.05mg/mL, 60mL/btl (Cardiacin) 就醫資訊 開立日 Order 開立者 住院,入院日:2016/11/21,出院日:2016/12/12科別:61一般小兒科,主治:王玠能 2016/12/2 BIDPC 0.20mL,總量:0.20mL

16. Post intervention
12/2
12/6
,Aspirin 100mg/tab (Ropal) 就醫資訊 開立日 Order 開立者 住院,入院日:2016/11/21,出院日:2016/12/12科別:61一般小兒科,主治:王玠能 2016/12/1 QDPC 10mg,總量:10mg PO
Clopidogrel 75mg/tab (Plavix) 就醫資訊 開立日 Order 開立者 住院,入院日:2016/11/21,出院日:2016/12/12科別:61一般小兒科,主治:王玠能 2016/12/1 QDPC 0.50mg
,Furosemide inj 針_利尿 20mg/2mL/amp(Rasitol) 就醫資訊 開立日 Order 開立者 住院,入院日:2016/11/21,出院日:2016/12/12科別:61一般小兒科,主治:王玠能 2016/12/2 Q8H 2.40mg,總量:2.40mg IVD ,1日 魏昱仁 2016/12/2 Q8H 20mg,總量:20mg IVD ,7日 蔡瑋峻 2016/12/1 STAT 2.40mg,總量:2.40mg IVD
:389636,Furosemide oral sol 液劑 10mg/mL, 120mL/btl (Fumide) 就醫資訊 開立日 Order 開立者 住院,入院日:2016/11/21,出院日:2016/12/12科別:61一般小兒科,主治:王玠能 2016/12/6 BID 0.20mL,總量:0.20mL PO
Digoxin elixir 液劑 0.05mg/mL, 60mL/btl (Cardiacin) 就醫資訊 開立日 Order 開立者 住院,入院日:2016/11/21,出院日:2016/12/12科別:61一般小兒科,主治:王玠能 2016/12/2 BIDPC 0.20mL,總量:0.20mL

17. Further survey
Brain MRI: Dysgenesis of corpus callosum with global hypoplasia
46,XX, normal karyotype
Array comparative genomic hybridization: deletion of 16p13.3, CREBBP gene deletion
-> Rubinstein Taybi syndrome
先是BRAIN ECHO看到 擔
poor postnatal height-weight growth, intellectual disability, microcephaly, dysmorphic facial features, broad thumbs, and big first toes心_____ syndrome

18. -> Rubinstein Taybi syndrome
Feature
Incidence (%)
Typical facial features
100
Intellectual disability
~100
Cryptorchidism
78-100
Microcephaly
35-94
Broad thumbs/halluces 96
Speech delay 90
Recurrent respiratory infections 75
Delayed bone age 74
Constipation
40-74
Talon cusps 73
Gastroesophageal reflux 68
EEG abnormalities
57-66
Renal anomalies 52
Refractive defects, glaucoma, retinopathy
>50
Feature
Incidence (%)
Congenital heart defects
24-38
Seizures 25
Keloids 24
Deafness
Growth retardation 21
Malignant tumors
3-10
先是BRAIN ECHO看到 擔
poor postnatal height-weight growth, intellectual disability, microcephaly, dysmorphic facial features, broad thumbs, and big first toes心_____ syndrome
-> Rubinstein Taybi syndrome
Italian Journal of Pediatrics201541:4

19. Palliative treatment of duct dependent pulmonary circulation
Discussion
Palliative treatment of duct dependent pulmonary circulation

20. The sixth embryonic aortic arch
Distal
 ductus arteriosus
Increased oxygen tension
PGE2 and PGI2 ↓
Proximal proximal branch pulmonary arteries

21. In our case
After birth, the abrupt increase in oxygen tension inhibits ductal smooth muscle voltage-dependent potassium channels, which results in an influx of calcium and ductal constriction.13 PGE2 and PGI2 levels fall because of metabolism in the now functioning lungs and elimination of the placental source. The medial smooth muscle fibers in the ductus contract, which results in wall thickening, lumen obliteration, and shortening of the ductus arteriosus. Functional complete closure usually occurs within 24 to 48 hours of birth in term neonates. Within the next 2 to 3 weeks, infolding of the endothelium along with subintimal disruption and proliferation result in fibrosis and a permanent seal.14 The resulting fibrous band with no lumen persists as the ligamentum arteriosum.

22. Choice of treatment in duct dependent pulmonary circulation
1. Corrective surgical therapy
2. Palliative systemic-to-pulmonary connection
modified Blalock-Taussig (B-T) shunt
pulmonary ductus arteriosus (PDA ) stent

23. Blalock-Taussig shunt
Modified Blalock-Taussig shunt (mBTS)
Classic Blalock-Taussig shunt
Originally the shunt sacrificed the subclavian artery (with a distal ligation) and the proximal portion is routed downwards to an end to side anastomosis with the ipsilateral branch of the pulmonary artery. The modified BT shunt nowadays uses a synthetic graft, usually expanded polytetrafluoroethylene (Gore-Tex®). 
preservation of the subclavian
artery; fewer technical problems with the anastomosis,
including ease of insertion and takedown; greater pulmonary
artery growth with less distortion of the pulmonary
arteries; and lower shunt failure rate

24. The use of B-T shunt From 1944 – 2006 in The Johns Hopkins Hospital
WILLIAMS, Jason A., et al. Two thousand Blalock-Taussig shunts: a six-decade experience. The Annals of thoracic surgery, 2007, 84.6:
SINGLE VENTRICLE
If pulmonary outflow is obstructed, the
findings are usually similar to those of tetralogy of Fallot: marked
cyanosis without heart failure. If pulmonary outflow is unobstructed,
the findings are similar to those of transposition with
VSD: minimal cyanosis with increasing heart failure.
TRICUSPID ATRESIA
Severely cyanotic neonates should be maintained on an intravenous infusion of prostaglandin E1 ( μg/kg/min) until a surgical aortopulmonary shunt procedure can be performed to increase pulmonary blood flow. The Blalock-Taussig procedure (Chapter 424.1) or a variation is the preferred anastomosis. next stage of palliation for patients with tricuspid atresia
involves the creation of an anastomosis between the superior vena cava and the pulmonary arteries (bidirectional Glenn shunt;
Fig A). This procedure is performed at usually between 3 and 6 mo of age.
 The Annals of thoracic surgery, 2007, 84.6:

25. As surgical techniques improved, mBTS became an option for…
Unstable Anatomic issues that mitigate against early total correction
However,
as surgical techniques improved and experience
with total correction of TOF grew, surgeons have opted
toward total correction earlier in life, leaving the BTS as
an option for neonates, some patients with extremely low
birth weight (3 kg), those who are unstable at the time
of presentation, or those who have anatomic issues that
mitigate against early total correction [21, 22].
the early part of this
series refers to 1944 through 1969 and the late part of the
series refers to 1970 through These cutoffs were
chosen arbitrarily to maintain whole decades within the
groups, as well as to evaluate the era of BTS before and
after the introduction of the modified BTS technique.
annual rate of BTS performed decreased significantly
when the early part of this series was compared with the
late part (66/year versus 9/year; p )

26. Complications of mBTS Early complication Chylothorax
Phrenic nerve paralysis
Shunt occlusion
Excess pulmonary blood flow
Late complication
Narrowing of the shunt
Serous fluid leak
Steal syndrome
Pulmonary artery hypertension
Distortion of pulmonary artery
Stenosis of pulmonary artery
as high as 36% of neonates and small children (14) 
Failure of the anastomosis site to grow
Fix length of the tube
Complicate the final surgery
Fluid leak:
PTFE grafts may be subject to serous fluid leakage with the formation of a seroma or graft occlusion due to hyperplasia of neointima.68 This complication occurred in 18.8% to 20% of the modified B-T shunts.69,70
Steal syndrome
Subclavian steal syndrome is one of the recognized complications of the classic B-T shunt. A modified B-T shunt has the advantage of a continued flow to the distal subclavian artery, and is free of a vertebral artery ligation; thus, a steal phenomenon should not be there. However, in situations of a small-sized subclavian artery, or any occlusion proximal to the origin of the vertebral artery, a subclavian steal syndrome might occur.89
Chylothorax:乳糜胸(chylothorax)是由於各種因素導致胸管(thoracic duct)阻塞或破裂，使乳糜液(chyme)溢入胸腔所致的病症。胸管是人體最大的淋巴管，源自第一腰椎前方的乳糜池，可以引流橫膈以下及橫膈以上之左半側的淋巴液。
Diaphragmatic paralysis: phrenic nerve injury was seen most frequently following
Classic or modified B-T shunts, accounting for
Up to 7% of all B-T shunts.75,76 small children did
Not tolerate phrenic nerve paralyses well, and required
Longer ventilatory support, and so more respiratory
Complications may have developed.77 transthoracic
Diaphragmatic placation is an effective treatment of
Phrenic nerve paralysis and achieve
Shunt stenosis: Innominate artery stenosis is an important cause of
diminished blood flow through a modified right B-T
shunt leading to a shunt occlusion. Routine angiography
might miss the diagnosis, and pressure gradients
and selective angiograms are necessary.78 As an alternative
to a second shunt operation, balloon angioplasty
was used to dilate the obstructed shunts, which
was reported to be effective in 91% of the patients.
 Circulation, 2014, :

27. Lt. Subclavian a.
How about PDA stent ?
PDA

28. The PDA stent
First report by Gibbs, et al. in 1992, early reports did not recommend the procedure Now considered an acceptable choice alternative to surgical shunt
Previous attempts to stent the neonatal duct with early generation, rigid, bare stents using relatively bulky, stiff wires, balloons, and sheaths frequently resulted in complications such as worsening cyanosis, bleeding, vessel rupture, duct spasm, tissue prolapse, or acute thrombosis. Additionally, incomplete covering of the duct frequently resulted in duct constriction, with inadequate pulmonary flow within hours or days after implantation.
The first implantation
was reported by Gibbs et al. [14] in two neonates with
pulmonary atresia, who died suddenly after the procedure
as a consequence of pulmonary artery perforation and
cardiac perforation, respectively.
Br Heart J 1992; 67: 240–5.
Circulation. 1999;99:

29. Indication of arterial duct stenting
High risk for conventional surgical palliation -low body weight -critical or with unusual arrangement of the pulmonary arteries
Low-risk neonates in whom early surgical repair may be planned
SANTORO, Giuseppe, et al. Arterial duct stenting: do we still need surgical shunt in congenital heart malformations with duct-dependent pulmonary circulation?. Journal of Cardiovascular Medicine, 2010, 11.11:
Journal of Cardiovascular Medicine, 2010, 11.11:

30. Pulmonary artery stenosis at duct insertion site
Contraindication:
Pulmonary artery stenosis at duct insertion site
Relative Contraindication :
Extreme ductal tortuosity
For long-term palliation

31. Choice of stent 3.5–5 mm depending on the size of the patient
Coronary stent
Overlapping to cover a long and tortuous duct
(e.g. Liberté stent; Boston Scientific, Natick, MA, USA)
The role of stents in the treatment of congenital heart disease: Current status and future perspectives

32. Severe stenosis of unstented ductus
ALWI, Mazeni. Stenting the ductus arteriosus: Case selection, technique and possible complications. Annals of pediatric cardiology, 2008, 1.1: 38.
(A) Long tubular ductus from the left subclavian artery. Only the distal half of the ductus was stented. Two months postductal stenting. Severe stenosis of unstented ductus adjacent to the stent (arrow). (B) Second stent implanted to cover the entire length of the ductus
 Annals of pediatric cardiology, 2008, 1.1: 38.

33. Immediate outcomes of PDA stenting
Successful in 80 to 100% of the cases
SA Heart Journal, 2013, 10.3:

34. Potential complications
Acute thrombosis
Spasm of the ductal arteriosus
Migration of expanded stent: if the pulmonary end of the ductus is not sufficiently constricted (>2.5 mm)
Journal of the American College of Cardiology, 2004, 44.2:

35. PDA stent produces significant growth of the PA
Shunt
Stent
SANTORO, Giuseppe, et al. Pulmonary artery growth following arterial duct stenting in congenital heart disease with duct‐dependent pulmonary circulation. Catheterization and Cardiovascular Interventions, 2009, 74.7:
1) McGoon's ratio: McGoon's ratio is calculated by dividing the sum of the diameters of RPA (at the level of crossing the lateral margin of vertebral column on angiogram) and LPA (just proximal to its upper lobe branch), divided by the diameter of aorta at the level above the diaphragm [DRPA /DDTAO)+( DLPA / DDTAO)]. An average value of 2.1 was noted in normal subjects. Ratio below 0.8 is deemed inadequate for complete repair of PA - VSD. 2) Nakata index: Nakata PA index is calculated from the diameter of PAs measured immediately proximal to the origin of upper lobe branches of the respective branch Pas [13] . The sum of the cross sectional area (CSA) of right and left PAs is divided by the body surface area of the patient [Nakata index = CSA of RPA (mm2) + CSA of LPA (mm2)/ BSA (m2)]. A Nakata index of >150 mm2/m2 is acceptable for complete repair without prior palliative shunt14. While Nakata index is widely used in preoperative assessment of adequacy of pulmonary vascular bed, it is not useful in patients with multifocal pulmonary blood supply, who are evaluated for single-stage repair of PA - VSD. UCSF group had proposed a total Neo-pulmonary artery index for use in patients with such complex lesions. 
unbalanced development of the central pulmonary vessels
The overall median follow-up was 189 days (range, 1-365; 196 days for mBTS vs 121 days for DS; P = .347). The overall survival to second-stage palliation, definitive repair, or 12 months was 87% (88% mBTS vs 85% DS, P = .742). During the 1-year follow-up period, second-stage palliation or definitive repair was performed in 27 patients (64%) in the mBTS group and 6 patients (38%) in the DS group (P = .334). The overall median interval to second-stage palliation or definitive repair was 189 days (range, ; 198 days for mBTS vs 130 days for DS; P = .197; Table 2). The initial postprocedural systemic oxygen saturation was similar between the 2 groups (mBTS, 83%; range, 72%-97% vs DS, 87%; range, 68%-95%; P = .077).
Catheterization and Cardiovascular Interventions, 2009, 74.7:

36. Stent durability Limited by Thrombosis Neointimal proliferation
Circulation. 1999;99:

37. Timing of definitive surgery
Durability of palliation was less compared to that of surgical shunt
The definitive surgery should be planned within months of ductal stenting
Journal of the American College of Cardiology, 2004, 44.2:

38. Overall survival to second-stage palliation
mBTS versus PDA stent
Overall survival to second-stage palliation
The Journal of thoracic and cardiovascular surgery, 2014, 147.1:

39. Overall interval to reintervention
mBTS versus PDA stent
Overall interval to reintervention
The Journal of thoracic and cardiovascular surgery, 2014, 147.1:

40. Take home message
The sixth pair of embryonic aortic arches: -the proximal portions of persist as the proximal pulmonary arteries -the distal portion persists as the ductus arteriosus
The mBTS is the most commonly created systemic–pulmonary shunt when early total correction is not suitable.
Complication of mBTS includes chylothorax, phrenic nerve injury, shunt occlusion, steal syndrome, PA distortion or stenosis.
PDA stent is an alternative treatment in selective cases.
PDA stent is less durable than surgical shunt, but could provide significant PA growth.

41. Thank you for listening!