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

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.