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Table of Contents
ORIGINAL ARTICLE  
Year : 2014  |  Volume : 17  |  Issue : 3  |  Page : 191-197
Modified Blalock Taussig shunt: Comparison between neonates, infants and older children


1 Department of Cardiac Anesthesia, Cardio-Thoracic Sciences Center, All India Institute of Medical Sciences, New Delhi, India
2 Department of Cardio-Thoracic and Vascular Surgery, Cardio-Thoracic Sciences Center, All India Institute of Medical Sciences, New Delhi, India

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Date of Submission14-Dec-2013
Date of Acceptance26-Apr-2014
Date of Web Publication3-Jul-2014
 

   Abstract 

Objective: The aim was to compare various pre-and post-operative parameters and to identify the predictors of mortality in neonates, infants, and older children undergoing Modified Blalock Taussig shunt (MBTS). Materials and Methods: Medical records of 134 children who underwent MBTS over a period of 2 years through thoracotomy were reviewed. Children were divided into three groups-neonates, infants, and older children. For analysis, various pre-and post-operative variables were recorded, including complications and mortality. Results: The increase in PaO 2 and SaO 2 levels after surgery was similar and statistically significant in all the three groups. The requirement of adrenaline, duration of ventilation and mortality was significantly higher in neonates. The overall mortality and infant mortality was 4.5% and 8%, respectively. Conclusion: Neonates are at increased risk of complications and mortality compared with older children. Age (<30 days), weight (<3 kg), packed red blood cells transfusion >6 ml/kg, mechanical ventilation >24 h and post shunt increase in PaO 2 (P Diff ) <25% of baseline PaO 2 are independent predictors of mortality in children undergoing MBTS.

Keywords: Modified Blalock Taussig shunt; Neonate; Congenital heart disease

How to cite this article:
Singh SP, Chauhan S, Choudhury M, Malik V, Talwar S, Hote MP, Devagourou V. Modified Blalock Taussig shunt: Comparison between neonates, infants and older children. Ann Card Anaesth 2014;17:191-7

How to cite this URL:
Singh SP, Chauhan S, Choudhury M, Malik V, Talwar S, Hote MP, Devagourou V. Modified Blalock Taussig shunt: Comparison between neonates, infants and older children. Ann Card Anaesth [serial online] 2014 [cited 2019 Oct 16];17:191-7. Available from: http://www.annals.in/text.asp?2014/17/3/191/135847



   Introduction Top


With the development of pediatric cardiac surgery and growing emphasis on primary corrective procedures for congenital heart disease, [1],[2],[3] the number of palliative procedures being performed have decreased progressively. The modified Blalock Taussig shunt (MBTS) is one such palliative procedure whose incidence has decreased over the past decade. The classic indications for performing a MBTS were limited to Tetralogy of Fallot, pulmonary atresia with or without adequate development of the right ventricle, single ventricle with rudimentary outlet, and diminutive pulmonary artery (PA). [4] The indications for MBTS have been extended to include congenital cyanotic heart defects presenting with hypercyanotic spells, failure to thrive and pulmonary arteries being too small for a safe corrective repair. [5] Other anomalies included are double outlet right ventricle, common inlet left ventricle, transposition of great arteries and Ebstein's anomaly. [5] The conventional approach for performing a MBTS is via thoracotomy incision, usually on the side opposite to the aortic arch (the right subclavian artery (SCA) arising from the innominate artery is more easily mobilized than the left SCA). However, sternotomy approach is advocated and practiced by some surgeons citing the disadvantages of thoracotomy approach including distortion of the branch PA, unbalanced growth of the branch PAs, delayed healing of thoracotomy wounds in children who remain cyanotic, onset of late scoliosis, development of collaterals from the chest wall to lung, phrenic nerve injury, damage to the sympathetic ganglia and cosmetic concerns in children undergoing MBTS via thoracotomy. [6],[7] Many surgeons still prefer to perform a MBTS via a thoracotomy. Shauq et al. [8] in their study have reported significantly longer ventilation time, inotropic support requirement, and Intensive Care Unit (ICU) and hospital stay in children undergoing MBTS through a sternotomy. In spite of wide clinical experience, the overall mortality with MBTS varies between 2.3% and 16% [9],[10],[11],[12] and around 9-11% [13],[14],[15] for neonatal Blalock Taussig (BT) shunts. This retrospective analysis was designed with the following objectives:

  1. To study the various pre-and post-operative parameters of children undergoing MBTS, including complications and mortality
  2. To compare children of different age groups with respect to the above parameters
  3. To identify the predictors of mortality in these children.



   Materials and methods Top


After institutional ethics committee approval, the medical records of all the children who underwent MBTS through thoracotomy from January 2011 to December 2012 were reviewed. One hundred and thirty-four children underwent MBTS over a period of 2 years. Of these 134 children, eight were neonates, 67 infants (1-12 months) and 59 were older children. The median age and weight of children were 305 days and 6 kg, respectively. The male to female ratio was 98:36. One hundred and three children had right sided and 31 children had left sided MBTS. The anesthetic technique was standardized and similar in all children. After intubation, as per institutional protocol, all children were initially ventilated with inspired O 2 concentration of 60% and an arterial blood gas analysis was done to check the SaO 2 and PaO 2 . During surgery, in the lateral decubitus position, efforts were made to maintain target peripheral oxygen saturation (SpO 2 ) of >80% and if required, O 2 concentration was increased to 100% to achieve the same. If the SpO 2 remained below 80% even after an increase of O 2 to 100%, the lower SpO 2 was accepted. The branch PA and SCA were dissected prior to the placement of a partial occlusive clamp on them. Before partially clamping the SCA, heparin 100 U/kg was administered to achieve an activated coagulation time (ACT) of about 200s. A Gore-Tex polytetrafluoroethylene (PTFE) graft (W L Gore and Associates, Inc., AZ, USA) was used as a conduit between SCA and branch PA. The size of PTFE graft was selected on the basis of body weight, 3.0 mm for preterm neonate or weight <2.5 kg, 3.5 mm for average neonate (2.5-3.5 kg), 4 mm for 3.5-6.0 kg and 5 mm for a >6 kg child. Intraoperatively, children with a preoperative hematocrit (Hct) >45% underwent either hemodilution or autologous blood withdrawal or both to maintain Hct around 45%. If the Hct was <45% before surgery no blood transfusion was given until the Hct fell <36% in neonates and <30% in older children. Dopamine 5 μg/kg/min was started initially to maintain a systolic blood pressure of >80 mmHg. Adrenaline 0.05 μg/kg/min followed by noradrenaline 0.05 μg/kg/min was started if systolic arterial pressure failed to increase >80 mmHg with dopamine. After the release of the partial clamp placed on branch PA, the patency of the shunt was assessed by a decrease in diastolic pressure, increase in pulse pressure and auscultation of shunt murmur through the endotracheal tube. On completion of the surgery, all the patients were shifted to ICU and monitored continuously for hemodynamic parameters and SpO 2 . Estimated blood volume was based on body weight: <3 kg, 90 mL/kg, 3-10 kg, 85 mL/kg and 10-20 kg, 80 mL/kg. Heparin was continued in the postoperative period at a rate of 10 U/kg/h and an ACT of 200s was maintained. Mediastinal chest tube drainage (MCTD), shunt patency and arterial blood gases were checked every hour after arrival in ICU for first 4-6 h. Any MCTD >5% of estimated blood volume for >3 consecutive hours or >10% of estimated blood volume at least for 1 h was taken as a criterion for mediastinal exploration. Shunt thrombosis in any child was an indication for reoperation. For analysis, following variables were collected, shunt size, emergency MBTS, previous MBTS, preoperative PaO 2 (P1) and SaO 2 (S1) after intubation and starting of mechanical ventilation. Any MBTS done after the completion of elective operative list and before the start of the next day's operative list was termed as emergency surgery. Patients receiving mechanical ventilation for >24 h before surgery were grouped as preoperative mechanically ventilated patients.

The following postoperative variables were collected: Inotropes and their duration; hemoglobin (Hb), SaO 2 (S2), PaO 2 (P2) on arrival in ICU; duration of mechanical ventilation and ICU stay; incidence of exploration, revision of the primary procedure, reintubation, and complications, including mortality. P2 and S2 values were the values taken on arrival in the ICU when the patient was ventilated with FiO 2 of 60%. The difference between P2-P1 (P Diff ) and S2-S1 (S Diff ) was calculated for each patient. Patients were divided into three groups-neonates (<1 month), other infants (1 month-1 year) and older children >1 year age for comparison.

Statistics

Data were analyzed using SPSS 20 (SPSS, Inc., Chicago, IL, USA). Age, weight and shunt size were expressed as median (range). String variables such as gender, side of shunt, emergency surgery, previous MBTS, prostaglandin infusion, reintubation, mediastinal exploration were expressed as a proportion. Complications and mortality were shown as a percentage. All other variables were mentioned as mean ± standard deviation. Nominal data with Gaussian distribution was compared using Analysis of Variance and non-Gaussian parameters with Kruskal-Wallis test. Chi-square test was used to compare categorical variables. P>0.05 was considered as significant. A univariate and logistic regression analysis was performed to identify the risk factors for death.


   Results Top


The various diagnoses for which MBTS was performed are listed in [Table 1]. Thirty-seven patients underwent emergency MBTS surgery. Two neonates were on prostaglandin infusion at the time of surgery and three children were on mechanical ventilation for >24 h before the surgery. The mean preoperative PaO 2 and SaO 2 were 39.54 ± 6.29 mmHg and 69.21 ± 7.67%, respectively. Of 134 children, 125 received inotropes of which dopamine was the most preferred inotrope and was used in all the children. Adrenaline was used as a second inotrope in 16 children and noradrenaline in three children. Thirty six children had packed red blood cell (pRBC) transfusion with a mean amount of 3.31 ± 6.79 ml/kg. The mean Hb, PaO 2 and SpO 2 post MBTS were 16.24 ± 2.84 g/dl, 54.83 ± 9.74 mmHg and 84.29% ±7.68%, respectively. The mean duration of mechanical ventilation and ICU stay were 16.22 ± 23.97 and 48.72 ± 57.01 h. Out of 134 children, 8 (5.97%) underwent tracheal reintubation, 13 (9.7%) underwent mediastinal exploration and 3 (2.2%) revision of the primary procedure. The various complications are summarized in [Table 2]. Excessive postoperative bleeding (12.68%) was the most common complication followed by low cardiac output. Overall mortality of 4.47% (6/134) was observed.
Table 1: Different diagnoses for which MBTS were done

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Table 2: Comparison between neonates (<1 month), infants (>1 month) and older children (>1 year)

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[Table 2] compares different variables among the three groups of neonates, infants and older children. There was a significant increase in the size of PTFE graft with age (3 mm vs. 4 mm vs. 5 mm). Requirement of adrenaline as an inotrope was maximum in neonates (100%) followed by infants and children. This difference was statistically significant (P < 0.001). The duration for dopamine infusion was significantly higher in neonates compared with the rest of the groups (P = 0.004). The Hb levels were significantly different among the groups with neonates having lowest and children the highest levels (14.38 ± 3.04 vs. 15.80 ± 2.77 vs. 16.98 ± 2.73, P = 0.01). Within the group comparison showed that the PaO 2 and SaO 2 levels significantly increased (P2 > P1 and S2 > S1) in all the three groups after MBTS surgery (P < 0.001 for both the variables in all the groups). However, on comparing the mean P Diff and S Diff values among the various groups, no statistically significant difference was found. The increase in PaO 2 and SaO 2 was similar in all the groups. Compared to infants and older children the duration of mechanical ventilation was significantly higher in neonates (P = 0.009; P = 0.005, respectively). Compared to the other groups mortality was significantly higher in the neonatal group (P = 0.004). Excessive postoperative bleeding was the most common complication in children (10/59) and infants (6/67). Three infants underwent shunt revision, two for shunt thrombosis and one for upsizing the shunt graft. None of the shunts were clipped. Lung collapse occurred in one infant and low cardiac output (? Sepsis) developed in another one and both underwent early tracheostomy.

Univariate analysis showed that increasing age, weight, shunt size and P Diff lead to increased survival whereas increases in adrenaline usage, amount of blood transfusion, duration of mechanical ventilation, tracheal reintubation and revision of the primary procedure were associated with decreased survival. Multivariate analysis using stepwise logistic regression identified age <30 days, weight <3 kg, blood transfusion >6 ml/kg, mechanical ventilation >24 h and increase in PaO 2 of <25% of preoperative PaO 2 as predictors of early mortality [Table 3].
Table 3:

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   Discussion Top


There has been a significant change in the practice and outcomes of BT shunt since it was first performed in 1945. [4] Earlier, the classic BT shunt was replaced by the MBTS where a PTFE graft is placed between the SCA and branch PA. Now the most widely used technique of de Leval [16] (via posterolateral thoracotomy) is being challenged by the proponents of sternotomy. [7],[8],[17] Odim et al. [7] reported that a MBTS was 4 times more likely to fail if performed via thoracotomy rather than sternotomy. Kandakure et al., [17] emphasized that thoracotomy approach can cause distal PA distortion and since the shunt is placed more centrally through sternotomy the growth of branch PAs is more uniform. In the authors' institution, the MBTS is performed by posterolateral thoracotomy because of the concerns of a resternotomy like injury to major vessels, increased bleeding and operative time.

In our study, the median age and weight of children was 305 days (3-3650 days) and 6 kg (2-20 kg). These values are higher as compared to other studies [13],[14],[15],[18],[19] We selected all the children undergoing MBTS surgery in a 2 year period, whereas other investigators defined age limits for their research and have concentrated on neonates. [10],[13],[14],[19],[20] Although, palliation with definite procedures is becoming common in young age, many older children still undergo MBTS because of complex anatomy, underdeveloped branch PAs and/or systemic desaturation (emergency MBTS). The preoperative SaO 2 and PaO 2 in our patients were 69.21% ±7.67% and 39.54 ± 6.29 mmHg, respectively. The preoperative SaO 2 in our study was higher in comparison to other study groups [14],[18],[19] because of two reasons-one, we measured the SaO 2 after intubation in the operation room and second only 28% (37 of 134) children underwent emergency shunt for acute systemic desaturation. The post MBTS SaO 2 was 84.29% ±7.68%, which is similar to other investigators who reported a post shunt SaO 2 between 77% and 89%. Even though children were of different ages in our study no significant difference was present in the preoperative and postoperative SaO 2 and PaO 2 among neonates, infants and older children. The SaO 2 and PaO 2 did increase significantly after the MBTS. In children with cyanotic heart disease the Hct of the patient influences the systemic SpO 2 significantly and since most of the children had Hct more than 65% (above which our arterial blood gas analyzer [GEM Premier 3000 Blood gas analyze; Instrumentation Laboratory, MA, USA] does not show any value) there was not much difference in the preoperative values of SaO 2 among different age groups. Similarly, in the postoperative period to improve shunt flow we maintained a Hct of 45% in all patients, [18] which might have nullified the difference in SaO 2 and PaO 2 . The duration of mechanical ventilation and ICU stay, in our study, were comparable with the study of Swain et al. (18.6 ± 3.3 h and 3.86 ± 2.06 days) whereas other studies [19],[20] have shown prolonged ventilation and ICU stays. This discrepancy might have arisen because these studies were done on neonates only and had small sample size. At our institution, we do not routinely ligate the patent ductus arteriosus (PDA); we under size the PTFE graft for MBTS if PDA is patent. Even with this practice none of our patients required clipping of the MBTS for excessive pulmonary flow shunt. One neonate did develop acute pulmonary edema in ICU but was successfully managed conservatively. In our study dopamine was the initial inotrope and adrenaline was added later on. Sixteen patients received adrenaline of which 50% were neonates. This is quite understandable as neonates have immature myocardium and heart rate dependent cardiac output. One study, indeed, classified adrenaline ± noradrenaline ± milrinone as normal inotropic support. [15] The most common complication in our study was postoperative bleeding. None of the patients developed any seroma, phrenic nerve palsy or sepsis. Shunt failure/thrombosis was infrequent, this could be attributed to regular use of heparin (10 U/kg/h) in initial postoperative period, and aspirin (5 mg/kg) after extubation. [21]

Neonates, in our study, compared to older children, showed lower Hb levels on ICU arrival and increased inotropes infusion, blood transfusion, duration of mechanical ventilation and mortality. Two neonates who died were 2.0 and 2.5 kg, both had 3.5 mm shunts, were on preoperative mechanical ventilation, received a blood transfusion for increased mediastinal drainage and one child had his trachea reintubated after extubation. Neonates tend to bleed more because of immature coagulation system, and are more prone to endotracheal tube displacements, over-sedation and pulmonary complications leading to prolonged mechanical ventilation. The overall mortality and infant mortality of 4.5% and 8%, respectively is comparable with other studies. [7],[15],[17],[21] No child older than 1 year died. This significant difference in mortality could be due to larger vessels, less vulnerable physiology and technically less demanding surgery in older children.

The different predictors of mortality after MBTS that have been described are weight <2 kg or 3 kg, shunt size, univentricular hearts, restrictive atrial septal defect, diagnosis of pulmonary atresia with intact interventricular septum and preoperative ventilation. [13],[19],[22] In our study, univariate analysis confirmed age, weight and shunt size as risk factors for mortality. Preoperative ventilation was not analyzed because none of the surviving children was on preoperative ventilation for >24 h. Three children required preoperative ventilation, two of them were neonates. All of them (three patients) died in the postoperative period. The need for preoperative ventilation denotes the precarious condition of these infants. [22] Other variables which influenced mortality were adrenaline use, reintubation and revision of the primary procedure. On multivariate analysis, age <30 days, weight <3 kg, pRBC transfusion >6 ml/kg, mechanical ventilation >24 h and post shunt increase in PaO 2 (P Diff ) <25% of preoperative PaO 2 were found to be independent predictors of mortality. The post shunt rise in PaO 2 (P Diff ) plays a crucial role in the postoperative weaning and recovery especially in children undergoing emergency procedures.

Limitations

It is a retrospective study and carries all the disadvantages inherent to a retrospective analysis. There are only eight neonates in the study; therefore, conclusions drawn in that population are inherently weak. The surgeries were performed by multiple surgeons, and therefore significant differences in hemostatic techniques may have been present. However, significant postoperative bleeding was seen in all the neonates, apparently, the postoperative blood loss in neonates is inherent to weak coagulation system and may not be related to surgical technique.


   Conclusion Top


It may be concluded that neonates undergoing MBTS require more inotropes, blood transfusion and ventilatory support compared to infants and older children. The mortality is highest in neonates followed by infants (>1 month) and children. Postoperative bleeding is the most common complication after shunt surgery. Age (<30 days), weight (<3 kg), pRBC transfusion >6 ml/kg, mechanical ventilation >24 h and post shunt increase in PaO 2 (P Diff ) <25% of baseline PaO 2 are independent predictors of mortality in children undergoing MBTS.

 
   References Top

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2.Sousa Uva M, Lacour-Gayet F, Komiya T, Serraf A, Bruniaux J, Touchot A, et al. Surgery for tetralogy of Fallot at less than six months of age. J Thorac Cardiovasc Surg 1994;107:1291-300.  Back to cited text no. 2
    
3.Hennein HA, Mosca RS, Urcelay G, Crowley DC, Bove EL. Intermediate results after complete repair of tetralogy of Fallot in neonates. J Thorac Cardiovasc Surg 1995;109:332-42, 344.  Back to cited text no. 3
    
4.Blalock A, Taussig HB. The surgical treatment of malformations of the heart in which there is pulmonary stenosis or pulmonary atresia. JAMA 1945;128:189-202.  Back to cited text no. 4
    
5.Yuan SM, Shinfeld A, Raanani E. The Blalock-Taussig shunt. J Card Surg 2009;24:101-8.  Back to cited text no. 5
    
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7.Odim J, Portzky M, Zurakowski D, Wernovsky G, Burke RP, Mayer JE Jr, et al. Sternotomy approach for the Modified Blalock-Taussig shunt. Circulation 1995;92:II256-61.  Back to cited text no. 7
    
8.Shauq A, Agarwal V, Karunaratne A, Gladman G, Pozzi M, Kaarne M, et al. Surgical approaches to the blalock shunt: Does the approach matter? Heart Lung Circ 2010;19:460-4.  Back to cited text no. 8
    
9.Kyger ER 3 rd , Reul GJ Jr, Sandiford FM, Wukasch DC, Hallman GL, Cooley DA. Surgical palliation of tricuspid atresia. Circulation 1975;52:685-90.  Back to cited text no. 9
    
10.Donahoo JS, Gardner TJ, Zahka K, Kidd BS. Systemic-pulmonary shunts inneonates and infants using microporous expanded polytetrafluoroethylene: Immediate and late results. Ann Thorac Surg 1980;30:146-50.  Back to cited text no. 10
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14.Swain SK, Dharmapuram AK, Reddy P, Ramdoss N, Raghavan SS, Kona SM. Neonatal Blalock-Taussig shunt: Technical aspects and postoperative management. Asian Cardiovasc Thorac Ann 2008;16:7-10.  Back to cited text no. 14
    
15.Dirks V, Prêtre R, Knirsch W, Valsangiacomo Buechel ER, Seifert B, Schweiger M, et al. Modified Blalock Taussig shunt: A not-so-simple palliative procedure. Eur J Cardiothorac Surg 2013;44:1096-102.  Back to cited text no. 15
    
16.de Leval MR, McKay R, Jones M, Stark J, Macartney FJ. Modified Blalock-Taussig shunt. Use of subclavian artery orifice as flow regulator in prosthetic systemic-pulmonary artery shunts. J Thorac Cardiovasc Surg 1981;81:112-9.  Back to cited text no. 16
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21.Al Jubair KA, Al Fagih MR, Al Jarallah AS, Al Yousef S, Ali Khan MA, Ashmeg A, et al. Results of 546 Blalock-Taussig shunts performed in 478 patients. Cardiol Young 1998;8:486-90.  Back to cited text no. 21
    
22.Petrucci O, O′Brien SM, Jacobs ML, Jacobs JP, Manning PB, Eghtesady P. Risk factors for mortality and morbidity after the neonatal Blalock-Taussig shunt procedure. Ann Thorac Surg 2011;92:642-51.  Back to cited text no. 22
    

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Correspondence Address:
Sarvesh Pal Singh
Department of Cardiac Anaesthesia, C N Center, All India Institute of Medical Sciences, New Delhi - 110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9784.135847

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    Tables

  [Table 1], [Table 2], [Table 3]

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