Reverse Potts-Shunt for Bridging to Transplant, Recovery or Long-term Palliation

Objective: Reverse (r) Potts-Shunts was introduced as an alternative to lung transplantation in patients who had idiopathic pulmonary artery hypertension (IPAH). We present a case series in which rPotts-Shunt palliation was used as an exit strategy in end-stage biventricular heart failure for weaning from cardio-pulmonary bypass (CPB) in advanced surgery of complex congenital heart disease and for long-term palliation.

Methods: In the past 5 years (y), 7 patients aging between 11months and 26y were referred to our institution with end-stage heart failure for consideration of heart and heart-lung transplantation. The cardiac morphologies ranged from borderline left ventricle, multiple pre-operated Shone-complex, supra-systemic PH after left heart surgery including coarctation repair, Eisenmenger-Syndrome based on un-operated Truncus arteriosus (TAC) in 21y old patient and one infant with acute Coxsackie myocarditis. In addition to in part complex surgical procedures rPotts-shunts were performed with PTFE-tube with diameters between 6 and 13 mm. In one patient with hybrid palliated borderline left ventricle as a newborn a bovine Melody^® valve was placed within an already stented duct during a follow-up open-heart surgical for mitral valve repair. The young woman with TAC with severe TAC-valve regurgitation was resuscitated by ECMO after minimal obstetric intervention. As an alternative to acute HLTX-listing, complete repair of the TAC was performed together with TAV-valve and ascending aorta replacement; a 12 mm. PTFE -tube was placed between PA-bifurcation and descending aortic arch. For weaning from CPB and to exchange a VSD-dependent Eisenmenger physiology in a duct-like right-to left shunt avoiding cyanosis of the coronary and cerebral circulation.

Results: All patients survived. The patient with inflammatory cardiomyopathy received a successful HTX; 1 patient with borderline left ventricle recovered with normal biventricular function but by a Melody-valve in mitral position; 2 patients with Potts-shunt and additional bilateral pulmonary banding awaiting still a bi-ventricular repair; 3 adult patients are long-term palliated one meanwhile 5 years, one 2.5 years and the TAC-repaired woman almost year.

Conclusion: In addition to the established reverse Potts-Shunt to palliate IPAH, the strategy back to “fetal-like” circulation might be attractive for weaning from CPB, bridging to transplant or recovery or as long-term palliation in bi-ventricular heart failure.