Use of pulmonary artery flow restrictors in neonates with congenital heart disease: Timing and technical considerations

Objective: Neonates with congenital heart disease often require restriction of pulmonary blood flow while awaiting definitive palliation or repair. Historically, these patients were managed with pulmonary artery banding. Recently, the use of transcatheter-modified Micro Vascular Plugs as pulmonary flow restrictors has presented a promising alternative for these high-risk patients. Methods: We report our experience with transcatheter pulmonary flow restrictors in neonates with congenital heart disease and increased pulmonary blood flow. Outcomes assessed included successful device placement, procedural complications, procedural mortality, late device migration, progression to surgery, and need for pulmonary artery repair at the time of surgical device removal. Results: Between 2023 and 2025, 9 neonates (median age 14 days) with congenital heart disease, pulmonary overcirculation, and other preoperative risk factors received transcatheter pulmonary flow restrictors. Two patients received a third pulmonary flow restrictor as a second procedure. Twenty pulmonary flow restrictors were placed (17 Micro Vascular Plug 7Q and 3 Micro Vascular Plug 9Q devices). All patients survived the procedure. There were 2 early device migrations and no other procedural complications. In 2 patients, late pulmonary flow restrictor migration left a right and left upper lobe artery unprotected, requiring additional pulmonary flow restrictors. Six patients were successfully bridged to surgery (median interval: 29.5 days), and 1 patient had the transcatheter device removed after 2 weeks. At surgery, the removal of pulmonary flow restrictors was uncomplicated, up to 5.5 months postimplantation, and no pulmonary artery repair was required. Conclusions: Transcatheter palliation using pulmonary flow restrictors is a safe and effective strategy for neonates with congenital heart disease and increased pulmonary blood flow. This approach offers a viable alternative to pulmonary artery banding for bridging high-risk patients to definitive surgical repair, including delayed Norwood.