Rethinking Neonatal Surgical Urgency: Effective Delay with Internal Flow Restrictors.

BACKGROUND: Neonates with complex congenital heart disease frequently develop pulmonary overcirculation, but early surgical intervention may be poorly tolerated due to physiologic instability, prematurity, or comorbidities. Percutaneous internal pulmonary flow restrictors offer an adjustable strategy to modulate pulmonary blood flow as a bridge-to-decision in high-risk infants. METHODS: We conducted a retrospective review of 38 neonates and infants undergoing percutaneous pulmonary flow restrictor placement at a single institution from March 2023 to August 2025. Hemodynamic (pulmonary-to-systemic flow ratio) and laboratory (creatinine, lactate) parameters were assessed pre- and post-placement. Outcomes included physiologic stabilization, subsequent management decisions, weight gain, repeat interventions, major device- or catheter-related complications, and post-surgical complications. RESULTS: Flow restrictor placement reduced pulmonary blood flow, with median pulmonary-to-systemic flow ratio decreasing from 3.6 to 0.84, with rapid improvement in lactate and creatinine. Thirty-one patients (82%) proceeded to definitive surgical intervention at a median of 16 days, with a median weight gain of 370 g. Four patients (13%) required repeat intervention to achieve adequate physiologic stabilization. Overall cohort mortality was 24% (7 preoperative, 2 postoperative), with no preoperative deaths among the repeat-intervention subgroup. Postoperative complications occurred in 19% (6/31) of surgical patients. Two major device-related complications occurred (2/38, 5%). CONCLUSIONS: Percutaneous pulmonary flow restrictors provide a feasible and adaptable bridge-to-decision strategy to temporize pulmonary overcirculation and support physiologic optimization in high-risk neonates. Iterative, patient-specific adjustment enables individualized flow modulation, while clinical trajectory and candidacy for definitive intervention are assessed.

Duke Scholars

Author Douglas Overbey Surgery, Cardiovascular and Thoracic Surgery

Author Kevin Dennis Hill Pediatrics, Cardiology

Author Joseph W Turek Surgery, Cardiovascular and Thoracic Surgery