Off-pump pulmonary valvotomy for pulmonary atresia with intact ventricular septum: a safe and effective alternative with comparable outcomes

Right ventricle (RV) decompression for pulmonary atresia with intact ventricular septum (PA/IVS) could be achieved surgically or percutaneously, yet transcatheter valvotomy is not widely accessible in remote regions and classic on-pump pulmonary valvotomy procedure carries risks of by pass in neonatal patients. We aim to summarize our 15-year’s surgical experience treating PA/IVS with on-pump valvulotomy, off-pump valvulotomy and hybrid techniques. From January 2010 to March 2025, 104 PA/IVS children who underwent off-pump, on-pump pulmonary valvulotomy or hybrid therapy in our hospital were retrospectively reviewed, including off-pump group (n = 56), on-pump group (n = 34) and hybrid group (n = 14). The postoperative mortality, operation time, early and mid-term follow-up of the three groups were analyzed. Both the off-pump and hybrid groups exhibited significantly shorter operative times, reduced vasoactive drug support, shorter intubation times, and shorter intensive care unit (ICU) and postoperative hospital stays compared to the on-pump group (P < 0.001). Cerebral, intestinal and renal oxygen monitor suggested that no obvious hypoxia was caused by clamping in off-pump procedure (P > 0.05). At final follow-up, RV hypoplasia, tricuspid Z score and pulmonary regurgitation were not significant among groups (P > 0.05). However, the hybrid group demonstrated a significantly higher rate of restenosis. The off-pump pulmonary valvotomy is an effective, safe and technical-friendly operation. It provides superior early outcomes compared to on-pump surgery and a lower restenosis rate relative to hybrid techniques, highlighting its value for broader adoption across medical centers.