3/11/2017 10th International Conference on Neonatal & Childhood - - PowerPoint PPT Presentation

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Potts’ shunt in pediatric pulmonary arterial hypertension

Damien Bonnet

M3C-Necker Enfants malades, Université Paris Descartes Centre de référence des Malformations Cardiaques Congénitales Complexes Centre de référence des Maladies Cardiaques Héréditaires ICarP, Institut Hospitalo-Universitaire IMAGINE, Paris, France

10th International Conference on Neonatal & Childhood Pulmonary Vascular Disease

JAMA 1946

Blalock Taussig Thomas Modified Blalock Deleval Waterston Potts

Different types of anastomoses

Potts shunt

Therapeutic algorithm in pediatric PAH

Ivy DD et al. JACC 2013

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Lung transplantation in children

(Lung Transplantations: january 1990 – june 2012)

Median survival (years): Adult = 5.6; Pediatric = 5.1

p = 0.4400 2014

• JHLT. 2014 Oct; 33(10): 1025-1033

Pediatric PAH Median survival 5.8 years Pediatric PAH Median survival 5.8 years

Death on list 7/26: 27% Death on list 7/26: 27%

Goldstein BS et al. J Heart Lung Transplant 2011

Operative death/acute graft failure 22% Operative death/acute graft failure 22%

Blanc J, Vouhé P, Bonnet D. NEJM 2004

First Potts case in pediatric PAH in 2004

Boudjemline Y et al. Circ Cardiovasc Interv 2013 Baruteau A et al. Ann Thorac Surg 2012 Baruteau A et al. Eur J Cardiovasc Surg 2015 Before PDA stenting After PDA stenting

Stenting of tiny arterial duct in PAH Parisian series

Mortality 15 %

• 36 children: 19 surgical- 7 stenting of tiny ducts- 10 percutaneous
• 6 deaths after procedure
• 3 major postoperative complications

– One transient paraplegia – One chylothorax – One tracheal stenosis requiring subsequent surgery

• 31 survivors

– One late death (stenting) : severe RSV infection – One transplantation for recurrent hemoptysis after percutaneous closure of the Potts’shunt

Baruteau A et al. Eur J Cardiovasc Surg 2015

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Baruteau A et al. Eur J Cardiovasc Surg 2015

Outcomes after Potts ‘shunt

Pros and cons

Pros

Improvement of WHO-FC Convert iPAH in Eisenmenger syndrome

supposed to have a better outcome

Wean patient from IV/SC prostanoids Improvement of RV function No death on the waiting list 15 % mortality compared to 27 % on the waiting

list + 22% in post-transplantation

Normal oxygenation of brain and coronary

arteries (vs. Atrioseptotomy)

• High mortality of the procedure
• Prognosis of Eisenmenger

syndrome might not be so good

Boudjemline Y et al. Circ Cardiovasc Interv 2013 Baruteau A et al. Ann Thorac Surg 2012

Cons

Immortality bias in Eisenmenger syndrome

Pros and cons

Pros

Improvement of WHO-FC Convert iPAH in Eisenmenger syndrome

supposed to have a better outcome

Wean patient from IV/SC prostanoids Improvement of RV function No death on the waiting list 15 % mortality compared to 27 % on the waiting

list + 22% in post-transplantation

Normal oxygenation of brain and coronary

arteries (vs. Atrioseptotomy)

• High mortality of the procedure
• Prognosis of Eisenmenger syndrome

might not be so good

• Simple palliation not a cure of PAH
• Risk of polycythemia
• Might increase the risk of bleeding

during a subsequent transplantation

Boudjemline Y et al. Circ Cardiovasc Interv 2013 Baruteau A et al. Ann Thorac Surg 2012

Cons

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Potts shunt

When to do a Potts’ shunt ?

Potts shunt ?

Ziljstra W et al. JACC 2014

Potts’ shunt at time of clinical worsening in children receiving triple therapy ? Place of Potts shunt in the treatment strategy

• Earlier ?

–When prostanoids are indicated ? –Before right heart failure –In all children with suprasystemic PAH on triple therapy ?

• Enlarging indications

–PAH associated with CHD – convert an Eisenmenger syndrome with intracardiac shunt in an Eisenmenger syndrome with PDA –Valved Potts’shunt in infrasystemic PAH with syncope

• Potts as a bridge to lung transplantation
• Improve technique and reduce immediate risk

–Percutaneous procedure

Bui MT et al. JTCS 2011 Paradela M et al. JTCS 2013 Latus H et al. J Heart Lung Transplant 2014 Bhamra-Ariza et al. JACC 2014 Bui MT et al. JTCVS 2011;142:1223-8

Animal model of valved Potts

Bui MT et al. JTCS 2011 Paradela M et al. JTCS 2013 Latus H et al. J Heart Lung Transplant 2014 Bhamra-Ariza et al. JACC 2014

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Percutaneous Potts’shunts

Initial experience

Esch JJ et al. J Heart Lung Transplant 2013 Schranz D et al EuroIntervention 2015

Percutaneous Potts’shunt

Technical aspects

Schranz D et al. Eurointervention 2015 Boudjemline Y et al. submitted Sizarov A et al. Heart 2016 Morphometric measurements on CT angiograms Bronchial arteries between PA and Aorta Contact area between PA and Aorta Cath Lab simulation

Optimization of perforation site

Pre

Percutaneous Potts’shunt

3/11/2017 6 Percutaneous Potts’shunt Percutaneous Potts’shunt Percutaneous Potts’shunt Percutaneous Potts’shunt

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Towards dedicated devices

Courtesy from Younes Boudjemline

Mathematic modelization of Potts’shunt

Flow velocity Pressure

Sizarov A, Boudjemline Y, et al. In preparation Berger RMF & Bonnet D, Eur Respir Rev 2010

Conclusion

The Potts shunt international cohort survey If you want to participate to this study, please contact Damien BONNET or Mark GRADY damien.bonnet@aphp.fr grady@kids.wustl.edu

Surgical, percutaneous, stenting of tiny PDA in pediatric PAH

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M3C-Pediatric PH group

Younes Boudjemline Marilyne Lévy Pascal Vouhé Olivier Raisky Diala Khraiche Magalie Ladouceur Isabelle Szezepanski Aleksander Sizarov Damien Bonnet