To compare outcomes of ductal stenting (DS) versus modified Blalock-Taussig shunt (mBTS) as initial palliation in neonates with functionally univentricular heart (FUH) and duct-dependent pulmonary blood flow, up to bidirectional cavo-pulmonary connection (BCPC).

We retrospectively analysed 192 neonates with FUH and duct-dependent pulmonary blood flow undergoing initial palliation with DS ( n = 39) or mBTS ( n = 153) between 2005 and 2025, using Cox proportional hazards models.

Median follow-up was 6.3 months including the postoperative period of BCPC. Low birth weight was more frequent in the DS group (28.2% vs 11.1%; P = 0.01). Survival at initial palliation, interstage, and post-BCPC was 85.7% (95% CI 81.9–91.5), 83.3% (95% CI 76.9–88.1), and 79.7% (95% CI 71.9–85.5), respectively, with no between-group differences (log-rank P > 0.8). Early postoperative morbidity, including NICU length of stay, duration of inotropic support, and mechanical ventilation was greater after mBTS (all P < 0.01). Reintervention rates were similar between DS and mBTS (≈ 23% overall), with no difference in time to reintervention, including when restricted to unplanned procedures. Patients initially palliated with DS underwent BCPC earlier (5.3[3.6–8.6] months vs 7.3[6.0–11.2] months, P = 0.05) and at lower body weight (5.9[5.0–7.9] Kg vs 6.9[5.7–8.2] Kg, P = 0.02). Branch pulmonary artery stenosis before BCPC was more frequent after mBTS ( P < 0.01). After adjustment, mBTS showed a non-significant trend toward higher overall mortality and reintervention before BCPC.

DS provides safe and effective palliation for neonates with FUH and duct-dependent pulmonary blood flow, with advantages in early recovery and a signal toward reduced mortality and reintervention.