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

BACKGROUND

Neonates with complex congenital heart disease frequently experience pulmonary overcirculation, but early surgical intervention may be poorly tolerated as a result of 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

A retrospective review was conducted 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) variables were assessed before and after placement of the flow restrictor. Outcomes included physiologic stabilization, subsequent management decisions, weight gain, repeat interventions, major device- or catheter-related complications, and postsurgical complications.

RESULTS

Flow restrictor placement reduced pulmonary blood flow, with median pulmonary-to-systemic flow ratio decreasing from 3.6 to 0.84 and with rapid improvement in lactate and creatinine values. 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 of 31) of surgical patients. Two major device-related complications occurred (2 of 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.