Aorto-Pulmonary Shunt Creation in Congenital Heart Disease: Different Indications, Various Modifications, but Common Technical Challenges.

Percutaneous creation of an aorto-pulmonary (AP) shunt has been explored in preclinical models for over 15 years, yet its clinical application remains limited. Surgical AP shunts are widely used to augment pulmonary blood flow in cyanotic congenital heart disease, but repeated thoracic operations and general anesthesia carry substantial risks in critically ill or surgically complex patients. A less invasive transcatheter alternative could therefore represent a transformative option. We report a case series of two pediatric patients in whom a percutaneous connection between the aorta and pulmonary artery was successfully established. Indications were severe cyanosis due to compromised pulmonary blood flow in one child and suprasystemic pulmonary arterial hypertension requiring decompression in the other. The procedures were technically feasible and resulted in the intended immediate hemodynamic effects, either by enhancing pulmonary perfusion or by enabling right-to-left shunting for right heart decompression. Conceptually, percutaneous AP shunt creation parallels the transcatheter Potts shunt, which is increasingly recognized as a therapeutic option in pulmonary arterial hypertension. Both approaches establish controlled communication between the aorta and pulmonary artery, adapted to distinct physiological settings. Our report represents, to our knowledge, the first description of percutaneous AP shunt creation to improve pulmonary blood flow and oxygenation in congenital heart disease, as well as the first percutaneous connection between the ascending aorta and the pulmonary artery. These cases illustrate the technical feasibility of catheter-based AP shunt creation in selected pediatric patients and support further evaluation of this approach.