Risk factors for mortality and morbidity after the neonatal Blalock-Taussig shunt procedure.

Perioperative advances have led to significant improvements in outcomes after many complex neonatal open heart procedures. Whether similar improvements have been realized for the modified Blalock-Taussig shunt, the most common palliative neonatal closed-heart procedure, is not known. Data were abstracted from The Society of Thoracic Surgeons Congenital Heart Surgery Database (2002 to 2009). Inclusion criteria were all neonates who received a modified Blalock-Taussig shunt with or without cardiopulmonary bypass, and with or without concomitant ligation of a patent ductus arteriosus. Discharge mortality was the primary end point. A composite morbidity end point one or more of the following: postoperative extracorporeal membrane oxygenation, low cardiac output, or unplanned reoperation. Associations with patient and procedural variables were assessed with univariable and multivariable analyses. The inclusion criteria were met by 1273 patients. The discharge mortality rate was 7.2%, and composite morbidity, as defined, was 13.1%. Primary diagnoses were classified as (1) those potentially amenable to biventricular repair (62%), (2) functionally univentricular hearts (22%), and (3) pulmonary atresia with intact ventricular septum (PA/IVS; 14%), and miscellaneous (2%). Discharge mortality stratified by primary diagnoses was PA/IVS (15.6%), functionally univentricular hearts (7.2%), and diagnoses potentially amenable to biventricular repair (5.1%). Need for preoperative ventilatory support, diagnosis of PA/IVS or functionally univentricular hearts, and any weight less than 3 kg, were risk factors for death. Preoperative acidosis or shock (resolved or persistent) and diagnosis of PA/IVS or functionally univentricular hearts were predictors of composite morbidity. Nearly 33% of the deaths occurred within 24 hours postoperatively, and 75% within the first 30 days. The mortality rate after the neonatal modified Blalock-Taussig shunt remains high, particularly for infants weighing less than 3 kg and those with the diagnosis of PA/IVS.

Petrucci O ，O'Brien SM ，Jacobs ML ，Jacobs JP ，Manning PB ，Eghtesady P ... -  《-》

A comparison of Blalock-Taussig shunts with and without closure of the ductus arteriosus in neonates with pulmonary atresia.

The question of whether to close the patent ductus arteriosus when performing primary modified Blalock-Taussig (MBT) shunt surgery in neonates is still not clearly answered. The aim of this report was to compare the results of closure versus nonclosure of the patent ductus arteriosus during MBT shunt surgery in neonates with pulmonary atresia. This retrospective study included neonates with pulmonary atresia who underwent primary MBT shunt surgery through a sternotomy approach at our institution between January 1997 and October 2010. Mortality, resuscitation events, and the need for reintervention within the first 48 postoperative hours were studied as primary outcomes. Sixty-two neonates (mean age 6.9±5.5 days) underwent a MBT procedure. The arterial duct was closed surgically in 31 patients, and left open in 31 patients. Compared with patients in whom the PDA was left open, patients with a surgically closed arterial duct had a higher incidence of resuscitation events (29.0% versus 0%, p=0.0012), reinterventions (35.5% versus 3.2%, p=0.0013), and higher early hospital mortality (9.7% versus 0%, p=0.038). Time to extubation and length of hospital stay did not differ between the two groups (p=0.16 and p=0.73, respectively). A trend toward a higher maximum vasoactive-inotropic score in the group with a closed duct was observed (median 13.5 versus 10, p=0.10). In newborns with pulmonary atresia, ductal closure during MBT shunt procedure is associated with increased incidence of resuscitation events, need for reintervention, and increased mortality during the early postoperative period.

Zahorec M ，Hrubsova Z ，Skrak P ，Poruban R ，Nosal M ，Kovacikova L ... -  《-》

Outcomes of systemic to pulmonary artery shunts in patients weighing less than 3 kg: analysis of shunt type, size, and surgical approach.

To evaluate outcomes of systemic to pulmonary artery shunts (SPS) in patients weighing less than 3 kg with regard to shunt type, shunt size, and surgical approach. Patients weighing less than 3 kg who underwent modified Blalock-Taussig or central shunts with polytetrafluoroethylene grafts at our institution from January 1, 2000, to May 31, 2011, were reviewed. Patients who had undergone other major concomitant procedures were excluded from the analysis. Primary outcomes included mortality (discharge mortality and mortality before next planned palliative procedure or definitive repair), cardiac arrest and/or extracorporeal membrane oxygenation (ECMO), and shunt reintervention. In this cohort of 80 patients, discharge survival was 96% (77/80). Postoperative cardiac arrest or ECMO occurred in 6/80 (7.5%), and shunt reintervention was required in 14/80 (17%). On univariate analysis, shunt reintervention was more common in patients with 3-mm shunts (11/30, 37%) compared with 3.5-mm (2/36, 6%) or 4-mm shunts (1/14, 7%) (P < .003). There were no statistically significant associations between shunt type, shunt size, or surgical approach and cardiac arrest/ECMO or mortality. Multiple logistic regression demonstrated that a shunt size of 3 mm (P = .019) and extracardiac anomaly (P = .047) were associated with shunt reintervention, whereas no variable was associated with cardiac arrest/ECMO or mortality. In this high-risk group of neonates weighing less than 3 kg at the time of SPS, survival to discharge and the next planned surgical procedure was high. Outcomes were good with the 3.5- and 4-mm shunts; however, shunt reintervention was common with 3-mm shunts.

Myers JW ，Ghanayem NS ，Cao Y ，Simpson P ，Trapp K ，Mitchell ME ，Tweddell JS ，Woods RK ... -  《-》

Modified Blalock-Taussig shunt versus ductal stenting for palliation of cardiac lesions with inadequate pulmonary blood flow.

The modified Blalock-Taussig shunt is the most commonly used palliative procedure for infants with ductal-dependent pulmonary circulation. Recently, catheter-based stenting of the ductus arteriosus has been used by some centers to avoid surgical shunt placement. We evaluated the durability and safety of ductal stenting as an alternative to the modified Blalock-Taussig shunt. A single-institution, retrospective review of patients undergoing modified Blalock-Taussig shunt versus ductal stenting was performed. Survival, procedural complications, and freedom from reintervention were the primary outcome variables. A total of 42 shunted and 13 stented patients with similar age and weight were identified. Survival to second-stage palliation, definitive repair, or 12 months was similar between the 2 groups (88% vs 85%; P = .742). The incidence of surgical or catheter-based reintervention to maintain adequate pulmonary blood flow was 26% in the shunted patients and 25% in the stented patients (P = 1.000). Three shunted patients (7%) required intervention to address contralateral pulmonary artery stenosis and 3 (7%) required surgical reintervention to address nonpulmonary blood flow-related complications. The need for ipsilateral or juxtaductal pulmonary artery intervention at, or subsequent to, second-stage palliation or definitive repair was similar between the 2 groups. Freedom from reintervention to maintain adequate pulmonary blood flow was similar between infants undergoing modified Blalock-Taussig shunt or ductal stenting as an initial palliative procedure. However, a greater percentage of shunted patients experienced procedure-related complications and distal branch pulmonary artery stenosis. Palliative ductal stenting appears to be a safe and effective alternative to modified Blalock-Taussig in selected infants.

McMullan DM ，Permut LC ，Jones TK ，Johnston TA ，Rubio AE ... -  《-》

Factors affecting death and progression towards next stage following modified Blalock-Taussig shunt in neonates.

The modified Blalock-Taussig shunt (BTS) is utilized to palliate neonates born with restrictive pulmonary blood flow including those with single ventricle (SV) or biventricular (BV) cardiac anomalies. We aim in the current study to report palliation outcomes of neonates with BTS and to examine factors affecting death and progression to the subsequent stage of palliation or repair. Between 2002 and 2012, 341 patients underwent BTS including 175 with SV and 166 with BV anomalies. Competing risk analysis modelled events after BTS (death or transplantation, transition to Glenn shunt or biventricular repair) and examined risk factors affecting outcomes. SV patients had a higher incidence of extracorporeal membrane oxygenation (ECMO) support requirement (12 vs 4%, P = 0.004) and unplanned cardiac reoperation (14 vs 7%, P = 0.051) than their BV counterparts. Additionally, hospital mortality was higher in SV than in BV patients (15 vs 3%, P < 0.001). In SV patients, competing risk analysis showed that, 2 years following BTS, 27% of patients had died or received transplantation and 73% had undergone the Glenn shunt. On multivariable analysis, factors associated with time until death or transplantation prior to Glenn were cardiopulmonary bypass [hazard ratio (HR) 3.6 (2.0-6.4), P < 0.001], unplanned cardiac reoperation [HR 2.4 (1.3-4.6), P = 0.007], pulmonary atresia [HR 2.0 (1.1-3.7), P = 0.026] and the shunt size/weight ratio [HR 1.3 (1.1-1.4) per 0.1 increase, P = 0.001]. In BV patients, competing risk analysis showed that, 2 years following BTS, 13% of patients had died or received transplantation, 85% had undergone biventricular repair and 2% were alive without biventricular repair. On multivariable analysis, factors associated with time until death or transplantation prior to biventricular repair were genetic syndromes and extracardiac malformations [HR 6.1 (2.0-18.2), P = 0.001], weight ≤2.5 kg [HR 5.6 (2.0-16.0), P = 0.001] and male gender [HR 3.4 (1.1-11.0), P = 0.041]. Palliation with BTS continues to be associated with significant operative morbidity and mortality. In addition to hospital death, there is an important interstage attrition risk prior to subsequent palliation or biventricular repair. Inherent patient characteristics (i.e. genetic syndromes and low weight) and anatomical details (i.e. SV, pulmonary atresia and concomitant cardiac anomalies) are associated with worse survival.

Alsoufi B ，Gillespie S ，Mori M ，Clabby M ，Kanter K ，Kogon B ... -  《-》