This international survey highlights the considerable heterogeneity in contemporary PDA-stent practice and associated HLHS management across diverse cardiac centers. Although PDA stenting has become an increasingly accepted alternative to surgical systemic-to-pulmonary shunts for duct-dependent pulmonary blood flow, several fundamental aspects of peri-procedural and interstage management remain variable. The findings underscore the absence of unified, evidence-based guidelines and the need for multicenter collaboration to optimize outcomes.

One of the most striking findings is the range of PGE management strategies. In single-source pulmonary blood flow, abrupt ductal closure can be catastrophic, prompting many operators to use a cautious, clinically guided titration approach. The continued use of low-dose PGE until the wire has crossed the ductus reflects an emphasis on procedural safety in the setting of complex ductal anatomy. Despite two decades of PDA-stent experience, there remains remarkably little published guidance to inform PGE titration [1,2,3,4,5,6,7,8, 17, 21]. The variability seen in this survey highlights an unmet need for prospective research comparing standardized titration strategies and assessing associations with spasm, access-site selection, procedural times, and early outcomes.

Antiplatelet therapy is another area lacking consensus. Although nearly half of respondents use dual antiplatelet therapy with aspirin and clopidogrel, the clinical evidence supporting this practice remains sparse [17, 23]. Data from small pediatric cohorts suggest target platelet inhibition with the commonly used 0.2 mg/kg/day clopidogrel dose, but the true impact of DAPT on stent patency and thrombosis prevention remains unclear, particularly given the bleeding risk in neonates. Similarly, platelet function testing remains infrequent, reflecting its uncertain benefit, practical limitations, and financial burden. The field would benefit from multicenter prospective registries examining thrombosis, bleeding rates, and reintervention according to antiplatelet regimen and platelet reactivity profiles.

Technical aspects of PDA-stent implantation continue to evolve, and this survey underscores ongoing variability in stent-length selection. Straight-line measurements risk underestimating the length needed to fully cover a tortuous duct, whereas central-line measurements risk excessive protrusion into adjacent vasculature [1,2,3, 5,6,7,8, 11,12,13]. The growing adoption of advanced imaging, including 3D angiography and CT-based modeling, reflects operators’ efforts to better characterize ductal anatomy. However, such technology is not universally available. The field may benefit from consensus statements delineating when each strategy may be optimal, ideally supported by multicenter outcome comparisons.

The survey also reveals considerable differences in institutional readiness for high-risk PDA stenting. ECMO availability ranged from never to always available, and surgical back-up also varied significantly. Centers without ECMO or surgical standby tended to restrict PDA stenting to anatomies deemed low risk, reflecting prudent resource-aware decision-making. Although PDA stenting generally demonstrates outcomes comparable or superior to surgical shunting in selected patients [9,10,11,12,13,14,15,16], these results may not be generalizable to settings with limited back-up resources. As PDA stenting continues to expand globally, scalable frameworks for safe implementation—including minimum resource recommendations—may be warranted.

Carotid access has emerged as an important strategy for vertical or tortuous ducts and was used percutaneously by nearly half of all respondents. Recent data reassure operators about neurologic and vascular safety when carotid access is performed in experienced centers [7, 8, 19]. Yet the long-term effects on carotid patency remain poorly defined. The widespread adoption of carotid access reported here suggests growing comfort among operators, but highlights the need for dedicated long-term vascular follow-up studies.

Regarding HLHS palliation, the majority of respondents favored the conventional Norwood approach for standard-risk infants. This aligns with contemporary multicenter analyses suggesting that hybrid palliation, while valuable for high-risk infants or specific institutional models, may confer increased procedural burden and reintervention without clear long-term survival benefit in standard-risk populations [24,25,26,27,28]. Nevertheless, the 15% adoption rate for primary hybrid Stage I reflects its continued role in select settings, especially where early surgical risk is prohibitive. As hybrid techniques continue to evolve, outcomes across different institutional models should be compared to define optimal patient selection.

Interstage management after Norwood remains another area of variability. While 70% of respondents discharge patients home with monitoring, the intensity and structure of these programs vary widely. Evidence clearly demonstrates that structured home-surveillance programs reduce interstage mortality [29,30,31]. The finding that some centers continue to hospitalize all or nearly all post-Norwood infants suggests persisting concerns regarding resource availability, family reliability, and outpatient monitoring infrastructure. Global harmonization of interstage monitoring protocols may therefore represent one of the most impactful next steps in improving survival.

Overall, this survey highlights an important tension in contemporary PDA-stent practice: while accumulating evidence supports PDA stenting as a safe and effective alternative to surgical shunting, significant practice variation persists across virtually all domains. Establishing best practices will require coordinated multicenter efforts, robust prospective registries, and consensus-based guidance documents addressing peri-procedural management, access strategy, stent selection, and interstage surveillance. Until such recommendations are developed, operators should emphasize multidisciplinary collaboration, careful patient selection, and institution-specific safety protocols to mitigate risk and improve outcomes.