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Simsek B, Ozyuksel A, Saygi M, Demiroluk S, Basaran M. Revisiting the central aortopulmonary shunt procedure. TURK GOGUS KALP DAMAR CERRAHISI DERGISI 2023; 31:207-214. [PMID: 37484647 PMCID: PMC10357854 DOI: 10.5606/tgkdc.dergisi.2023.24247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 02/28/2023] [Indexed: 07/25/2023]
Abstract
Background In this study, we present our experience with the central aortopulmonary shunt technique with interposing a polytetrafluoroethylene graft between main pulmonary artery (end-to-end) and the ascending aorta (side-to-side) in a variety of cyanotic congenital heart defects. Methods Between January 2019 and June 2022, a total of 10 patients (6 males, 4 females; mean age: 4.3±2.8 months; range, 5 days to 10 months) with hypoplastic central pulmonary arteries who underwent central aortopulmonary shunt procedure were retrospectively analyzed. Demographic characteristics, preoperative, operative, and postoperative data of the patients were recorded. The Nakata indices of the patients were also noted before the procedure, as well as before the second stage of palliation or definitive repair. Results Four (40%) patients were operated as the first-step palliation for univentricular circulation. Six (60%) patients had well-developed ventricles and were palliated to be treated with total correction. The median follow-up after the procedure was 12 (range, 8 to 16) months. The mean systemic arterial saturation level at room air was 89.3±2.9% during follow-up. No mortality was observed in any patient. Conclusion A central aortopulmonary shunt procedure provides a reliable antegrade blood flow with a relatively non-challenging surgical technique that offers sufficient growth for the hypoplastic and confluent central pulmonary arteries with a very low risk of shunt thrombosis and overflow.
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Affiliation(s)
- Baran Simsek
- Department of Cardiovascular Surgery, Medicana International Hospital, Istanbul, Türkiye
| | - Arda Ozyuksel
- Department of Cardiovascular Surgery, Medicana International Hospital, Istanbul, Türkiye
- Department of Cardiovascular Surgery, Biruni University, Istanbul, Türkiye
| | - Murat Saygi
- Department of Pediatric Cardiology, Medicana International Hospital, Istanbul, Türkiye
| | - Sener Demiroluk
- Department of Anesthesiology and Reanimation, Medicana International Hospital, Istanbul, Türkiye
| | - Murat Basaran
- Department of Cardiovascular Surgery, Medicana International Hospital, Istanbul, Türkiye
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Tarca A, Peacock G, McKinnon E, Andrews D, Saundankar J. A Single-Centre Retrospective Review of Modified Blalock-Taussig Shunts: A 22-Year Experience. Heart Lung Circ 2023; 32:405-413. [PMID: 36621393 DOI: 10.1016/j.hlc.2022.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 11/21/2022] [Accepted: 12/07/2022] [Indexed: 01/09/2023]
Abstract
INTRODUCTION This single-centre retrospective study explores demographics and outcomes of patients who underwent a modified Blalock-Taussig shunt (MBTS) over a 22-year period. The predominant surgical approach in this study is a lateral thoracotomy, in contrast to a midline sternotomy. Risks and outcomes of this approach are compared with national and international literature. MATERIALS AND METHODS Demographic, anatomical, clinical, surgical and outcome data of all patients who underwent a MBTS between 2000 and 2022 were collected and analysed, excluding Norwood procedures, which are not performed at this institution. Short- and long-term morbidity and mortality is described. RESULTS Over the 22-year study period, 185 MBTS were performed in 162 patients, at a median age of 16 days (interquartile range [IQR] 5-59 days) and weight of 3.47 kg (IQR 3-4.25 kg, minimum weight 2 kg). Of these, 79% of patients had a biventricular circulation. Cardiac diagnoses included both univentricular and biventricular anatomy; tetralogy of Fallot (TOF) (36%), transposition of the great arteries/ventricular septal defect/pulmonary stenosis (TGA/VSD/PS) (11%), pulmonary atresia with intact ventricular septum (PA/IVS) (23%), pulmonary atresia with ventricular septal defect (PA/VSD) (14%), other (16%). The most common size of MBTS was 4 mm (71%); 93% were performed via a lateral thoracotomy. There were 47 cases of major operative morbidity, which did not differ significantly with cardiac diagnosis. Overall all-cause mortality was 13.5%. Early operative mortality was 4.3%. Mortality varied with cardiac diagnosis, 6% with TOF and 19% with PA/IVS. There was no era effect on mortality rates, however a lower frequency of major morbidity (23% vs 7%, p=0.03) was observed in the most recent third of the study period. Risk factors for shunt reintervention or mortality included weight <2.5 kg (HR=2.79 [1.37, 5.65], p=0.005), and pre- (HR=3.31 [1.86, 5.9], p<0.001) or postoperative lactic acidosis (HR=1.37 [1.25,1.5], p<0.001). These rates are comparable to those in the literature, with the predominant approach a midline sternotomy. CONCLUSION Mortality rates and risk factors for adverse outcomes are comparable to those previously reported for both univentricular and biventricular groups. These results highlight that outcomes of MBTS performed via lateral thoracotomy are comparable to those by midline sternotomy as reported in the literature. Operating via the lateral approach may be advantageous as it avoids the complications of a midline sternotomy.
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Affiliation(s)
- Adrian Tarca
- Children's Cardiac Centre, Perth Children's Hospital, Perth, WA, Australia.
| | - Giulia Peacock
- Children's Cardiac Centre, Perth Children's Hospital, Perth, WA, Australia
| | | | - David Andrews
- Department of Cardiothoracic Surgery, Perth Children's Hospital, Perth WA, Australia
| | - Jelena Saundankar
- Children's Cardiac Centre, Perth Children's Hospital, Perth, WA, Australia
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3
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Long-term outcomes of staged repair of tetralogy of Fallot. J Thorac Cardiovasc Surg 2022; 165:2169-2180.e3. [PMID: 36116957 DOI: 10.1016/j.jtcvs.2022.07.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 07/18/2022] [Accepted: 07/24/2022] [Indexed: 11/21/2022]
Abstract
BACKGROUND The optimal management strategy for symptomatic young infants with tetralogy of Fallot (TOF) is yet to be determined. We aimed to evaluate the long-term outcomes of a staged approach with initial shunt palliation followed by complete repair. METHODS Between January 1993 and July 2021, 160 children with TOF underwent a systemic-to-pulmonary shunt at our institution, including 65 neonates (41%). The mean duration of follow-up was 12.3 ± 8.1 years. RESULTS Hospital mortality was 3% (4 of 160), all occurring in patients with a shunt size-to-weight ratio ≥1.2 mm/kg. Composite morbidity-defined as cardiac arrest, postoperative mechanical circulatory support, or unplanned reoperation-occurred in 21% (33 of 160). On multivariable analysis, a shunt size-to-weight ratio ≥1.2 mm/kg and prematurity were independent predictors of composite morbidity. Interstage mortality was 3% (4 of 156). A limited transannular patch was used in 75% (113 of 150) of TOF repairs. Actuarial survival at 20 years after shunt was 90% (95% confidence interval [CI], 79%-95%). Actuarial freedom from reinterventions at 20 years after TOF repair was 40% (95% CI, 28%-52%). Neonates had comparable composite morbidity, mortality, and late risk of reinterventions to older children. CONCLUSIONS Staged repair of TOF in symptomatic young infants results in low mortality but high rates of reinterventions at long-term follow-up. A shunt size-to-weight ratio ≥1.2 mm/kg is a significant risk factor for mortality and morbidity prior to complete repair. Neonates undergoing shunt insertion have comparable outcomes to older children.
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Tseng SY, Truong VT, Peck D, Kandi S, Brayer S, Jason DP, Mazur W, Hill GD, Ashfaq A, Goldstein BH, Alsaied T. Patent Ductus Arteriosus Stent Versus Surgical Aortopulmonary Shunt for Initial Palliation of Cyanotic Congenital Heart Disease with Ductal-Dependent Pulmonary Blood Flow: A Systematic Review and Meta-Analysis. J Am Heart Assoc 2022; 11:e024721. [PMID: 35766251 DOI: 10.1161/jaha.121.024721] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background In patients with ductal-dependent pulmonary blood flow, initial palliation includes catheter-based patent ductus arteriosus (PDA) stent or surgical aortopulmonary shunt (APS). This meta-analysis aimed to compare outcomes between PDA stent and APS. Methods and Results A comprehensive literature search yielded six retrospective observational studies. Pooled adjusted hazard ratios (HR) were included to control for covariates and assess time to event analysis. Of 757 patients, 243 (32.1%) underwent PDA stent and 514 (67.9%) underwent APS. Pulmonary atresia with intact ventricular septum and expected biventricular repair were more common with PDA stent compared with APS (39.6% versus 21.2%, P<0.001 and 57.9% versus 46.6%, P=0.007, respectively). There was no statistically significant difference in mortality between PDA stent and APS (HR, 0.71; [95% CI, 0.26-1.93]; P=0.50). PDA stent was associated with lower risk of postprocedural complications (odds ratio [OR], 0.45; [95% CI, 0.25-0.81]; P=0.008), mechanical circulatory support (OR, 0.27; [95% CI, 0.09-0.79]; P=0.02), and shorter intensive care unit length of stay (-4.03 days; [95% CI, -5.99 to -2.07]; P<0.001), hospital length of stay (-5.54 days; [95% CI, -9.20 to -1.88]; P=0.003), and duration of mechanical ventilation (-3.41 days; [95% CI, -5.29 to -1.52]; P<0.001). There was no difference in pulmonary artery growth or hazard of unplanned reintereventions. Conclusions PDA stent has a similar hazard of mortality compared with APS. Benefits to PDA stent include shorter duration of mechanical ventilation, shorter hospital length of stay, and fewer complications. Differences in patient characteristics exist with more patients with pulmonary atresia with intact ventricular septum and expected biventricular repair undergoing PDA stent.
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Affiliation(s)
- Stephanie Y Tseng
- The Heart Center Nationwide Children's Hospital Columbus OH.,The Heart Institute, Cincinnati Children's Hospital Medical Center Cincinnati OH
| | | | - Daniel Peck
- The Heart Institute, Cincinnati Children's Hospital Medical Center Cincinnati OH
| | - Sneha Kandi
- Northeast Ohio Medical University Rootstown OH
| | - Samuel Brayer
- The Heart Institute, Cincinnati Children's Hospital Medical Center Cincinnati OH
| | - Don P Jason
- University of Cincinnati College of Medicine Cincinnati OH
| | | | - Garick D Hill
- The Heart Institute, Cincinnati Children's Hospital Medical Center Cincinnati OH.,Department of Pediatrics University of Cincinnati College of Medicine Cincinnati OH
| | - Awais Ashfaq
- Heart Institute Johns Hopkins All Children's Hospital St. Petersburg FL
| | - Bryan H Goldstein
- The Heart Institute, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine Pittsburgh PA
| | - Tarek Alsaied
- The Heart Institute, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine Pittsburgh PA
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Wardoyo S, Makdinata W, Wijayanto MA. Perioperative strategy to minimize mortality in neonatal modified Blalock–Taussig–Thomas Shunt: A literature review. CIRUGIA CARDIOVASCULAR 2022. [DOI: 10.1016/j.circv.2021.04.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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Headrick AT, Qureshi AM, Ghanayem NS, Heinle J, Anders M. In-hospital Morbidity and Mortality Following Modified Blalock-Taussig-Thomas Shunts. Ann Thorac Surg 2021; 114:168-175. [PMID: 34838515 DOI: 10.1016/j.athoracsur.2021.11.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 09/20/2021] [Accepted: 11/02/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND The modified Blalock-Taussig-Thomas shunt (mBTTs) is a critically important palliation for patients with insufficient pulmonary blood flow associated with congenital heart disease. Following creation of a mBTTs, patients experience high rates of early postoperative morbidity and mortality. METHODS This is a single-institution retrospective cohort study. A query of the Society of Thoracic Surgeons database identified relevant patients whose health records were manually queried for echocardiography and operative reports. Patients with ductal-dependent systemic circulation were excluded. Primary outcomes were early serious adverse events and in-hospital mortality. Secondary outcomes were time to primary outcomes and postoperative lengths of stay. We investigated the correlation of demographics, presence of competitive pulmonary blood flow, and surgical and anatomic factors on outcomes. RESULTS After exclusions, our cohort resulted in 155 patients. 33 (21.3%) patients experienced an early serious adverse event, ten (6.5%) early shunt malfunction, and 11 (7.1%) in-hospital mortality. Smaller shunt size, smaller shunted pulmonary artery size, surgical approach, and site of proximal shunt anastomosis were independently associated with morbidity and mortality. CONCLUSIONS Anatomical elements imparting increased resistance along the mBTTs predispose to increased morbidity and mortality, particularly in the early postoperative period. Despite the significant heterogeneity of patients receiving such shunts, similar risk profiles are observed regardless of lesion or presence of competitive flow. Surgical approach via thoracotomy with shunt anastomosis to the subclavian artery, where feasible, results in the subclavian artery as the point of natural resistance allowing for placement of larger shunts, yielding lower morbidity and mortality.
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Affiliation(s)
- Andrew T Headrick
- Department of Pediatrics, Division of Pediatric Cardiology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas.
| | - Athar M Qureshi
- Department of Pediatrics, Division of Pediatric Cardiology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Nancy S Ghanayem
- Department of Pediatrics, Section of Critical Care Medicine, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas; Department of Pediatrics, Section of Critical Care Medicine, University of Chicago, Chicago, Illinois
| | - Jeffrey Heinle
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Congenital Heart Surgery, Texas Children's Hospital, Houston, Texas
| | - Marc Anders
- Department of Pediatrics, Section of Critical Care Medicine, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
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Shaikh S, Al-Mukhaini KS, Al-Rawahi AH, Al-Dafie O. Outcomes of Infants Undergoing Modified Blalock-Taussig Shunt Procedures in Oman: A retrospective study. Sultan Qaboos Univ Med J 2021; 21:457-464. [PMID: 34522413 PMCID: PMC8407913 DOI: 10.18295/squmj.8.2021.125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Revised: 08/06/2020] [Accepted: 08/26/2020] [Indexed: 12/03/2022] Open
Abstract
Objectives A modified Blalock-Taussig (mBT) shunt procedure is a common palliative surgery used to treat infants and children with cyanotic congenital heart disease (CCHD). This study aimed to report the outcomes of infants and children undergoing mBT shunt procedures in Oman. In addition, risk factors associated with early mortality, inter-stage mortality and reintervention were assessed. Methods This retrospective cohort study was conducted from January 2016 to December 2018 at the National Heart Centre, Muscat, Oman. All paediatric patients with CCHD undergoing mBT shunt procedures as a primary palliative procedure during this period were included. Data were retrieved from electronic hospital records. Kaplan-Meier survival curves were used to describe overall survival. Results A total of 50 infants and children were included in this study. The in-hospital mortality and interstage mortality rates were 10% and 6.7%, respectively. Preoperative mechanical ventilation (odds ratio [OR] = 3.00, 95% confidence interval [CI]: 1.98–4.76; P = 0.007) and cardiopulmonary bypass (OR = 4.09, 95% CI: 2.44–6.85; P = 0.002) were significant risk factors for early mortality. In-hospital and interval surgical reintervention rates were 12% and 13.3%, respectively. Following the primary shunt procedure, the median time to second-stage surgery was 15.5 months (range: 5.0–34.0 months). Conclusion The findings of this study support those reported in international research regarding the risks associated with mBT shunt surgeries. In particular, preoperative mechanical ventilation and cardiopulmonary bypass were significant risk factors for early mortality.
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Affiliation(s)
- Samiuddin Shaikh
- Department of Pediatric Intensive Care, Royal Hospital, Muscat, Oman
| | | | | | - Omer Al-Dafie
- Department of Pediatric Intensive Care, Royal Hospital, Muscat, Oman
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8
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Ide Y, Tachimori H, Hirata Y, Hirahara N, Ota N, Sakamoto K, Ikeda T, Minatoya K. Risk analysis for patients with a functionally univentricular heart after systemic-to-pulmonary shunt placement. Eur J Cardiothorac Surg 2021; 60:377-383. [PMID: 33712829 DOI: 10.1093/ejcts/ezab077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Revised: 12/14/2020] [Accepted: 01/13/2021] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES To investigate risk factors for mortality after systemic-to-pulmonary (SP) shunt procedures in patients with a functionally univentricular heart using the Japan Cardiovascular Surgery Database registry. METHODS Clinical data from 75 domestic institutions were collected. Overall, 812 patients with a functionally univentricular heart who underwent initial SP shunt palliation were eligible for analysis. Patients with pulmonary atresia with an intact ventricular septum and patients with a SP shunt as part of the Norwood procedure were excluded. Risk factors for 30- and 90-day mortalities were analysed using a logistic regression model. RESULTS Median age and body weight at SP shunt placement were 41 days and 3.6 kg, respectively. Modified Blalock-Taussig shunt, central shunt and other types of SP shunts were applied in 689 (84.9%), 94 (11.8%) and 30 (3.7%) patients, respectively. Cardiopulmonary bypass was utilized in 410 patients (51%) for 128 min (median, 19-561). There were 411 isolated SP shunt procedures. Median hospital stay was 27 days, and 742 (91.4%) patients were discharged. The 30- and 90-day mortality rates were 3.4% and 6.0%, respectively. Placement of a central shunt was identified as a risk factor for 30-day mortality, while lower body weight, preoperative ventilator support, right atrial isomerism and coexistence of major aortopulmonary collateral arteries and an unbalanced atrioventricular septal defect were identified as risk factors for 90-day mortality. CONCLUSIONS SP shunt carries a high mortality rate in patients with a functionally univentricular heart when it is performed in smaller patients with complex cardiac anomalies.
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Affiliation(s)
- Yujiro Ide
- Department of Cardiovascular Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Hisateru Tachimori
- Department of Healthcare Quality Assessment, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.,Department of Clinical Epidemiology, Translational Medical Center, National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Yasutaka Hirata
- JCVSD-Congenital Section, Japan Cardiovascular Surgery Database, Tokyo, Japan
| | - Norimichi Hirahara
- Department of Health Policy and Management, School of Medicine, Keio University, Tokyo, Japan
| | - Noritaka Ota
- Department of Cardiovascular and Thoracic Surgery, Ehime University School of Medicine, Toon, Japan
| | - Kisaburo Sakamoto
- Department of Cardiovascular Surgery, Mt. Fuji Shizuoka Children's Hospital, Shizuoka, Japan
| | - Tadashi Ikeda
- Department of Cardiovascular Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Kenji Minatoya
- Department of Cardiovascular Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
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Risk Factors of Thrombotic Complications and Antithrombotic Therapy in Paediatric Cardiosurgical Patients. ACTA BIOMEDICA SCIENTIFICA 2021. [DOI: 10.29413/abs.2021-6.2.9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
The development of cardiosurgical care for paediatric and neonatal patients is undergoing the rapid growth. Complex, multi-stage reconstructive operations and the use of invasive monitoring are associated with high risk of venous and arterial thrombosis.The cardiac surgery patient is inherently unique, since it requires controlled anticoagulation during cardiopulmonary bypass. Moreover, the most cardiovascular pediatric patients require antithrombotic measures over the perioperative period. In addition to medication support with the use of various groups of antithrombotic agents, vascular access management is justified in order to minimize the risk of thromboembolic complications, which can affect both the functional status, and common and inter-stage mortality.The purpose of this review was to systematize the available data on risk factors contributing to the development of thrombotic complications in patients with congenital heart disease.An information search was carried out using Internet resources (PubMed, Web of Science, eLibrary.ru); literature sources for period 2015–2020 were analysed. As a result of the analysis of the literature data age-dependent features of the haemostatic system, and associated with the defect pathophysiology, and undergone reconstructive interventions were described. The issues of pathophysiology of univentricular heart defects and risk factors associated with thrombosis were also covered.Moreover, aspects of intraoperative anti-thrombotic support are discussed, as well as measures to prevent thromboembolic complications in this population.Coordinated actions of haematologists, cardiologists, anaesthesiologists, intensivists, and cardiac surgeons will allow achieving a fine balance between risks of bleeding and thrombosis in the population of paediatric patients undergoing cardiovascular surgery.
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Predictors of death after receiving a modified Blalock-Taussig shunt in cyanotic heart children: A competing risk analysis. PLoS One 2021; 16:e0245754. [PMID: 33481924 PMCID: PMC7822344 DOI: 10.1371/journal.pone.0245754] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Accepted: 01/06/2021] [Indexed: 11/19/2022] Open
Abstract
Objective To determine risk factors affecting time-to-death ≤90 and >90 days in children who underwent a modified Blalock-Taussig shunt (MBTS). Methods Data from a retrospective cohort study were obtained from children aged 0–3 years who experienced MBTS between 2005 and 2016. Time-to-death (prior to Glenn/repair), time-to-alive up until December 2017 without repair, and time-to-progression to Glenn/repair following MBTS were presented using competing risks survival analysis. Demographic, surgical and anesthesia-related factors were recorded. Time-to-death ≤90 days and >90 days was analyzed using multivariate time-dependent Cox regression models to identify independent predictors and presented by adjusted hazard ratios (HR) and 95% confidence intervals (CI). Results Of 380 children, 119 died, 122 survived and 139 progressed to Glenn/repair. Time-to-death probability (95% CI) within 90 days was 0.18 (0.14–0.22). Predictors of time-to-death ≤90 days (n = 63) were low weight (<3 kg) (HR 7.6, 95% CI:2.8–20.4), preoperative ventilator support (HR 2.7, 95% CI:1.3–5.6), postoperative shunt thrombosis (HR 5.0, 95% CI:2.4–10.4), bleeding (HR 4.5, 95% CI:2.1–9.4) and renal failure (HR 4.1, 95% CI:1.5–10.9). Predictors of time-to-death >90 days (n = 56) were children diagnosed with pulmonary atresia with ventricular septal defect and single ventricle (compared to tetralogy of fallot) (HR 3.2, 95% CI:1.2–7.7 and HR 3.1, 95% CI:1.3–7.6, respectively), shunt size/weight ratio >1.1 vs <0.65 (HR 6.8, 95% CI:1.4–32.6) and longer duration of mechanical ventilator (HR 1.002, 95% CI:1.001–1.004). Shunt size/weight ratio ≥1.0 (vs <1.0) and ≥0.65 (vs <0.65) were predictors for overall time-to-death in neonates and toddlers, respectively (HR 13.1, 95% CI:2.8–61.4 and HR 7.8, 95% CI:1.7–34.8, respectively). Conclusions Perioperative factors were associated with time-to-death ≤90 days, whereas particular cardiac defect, larger shunt size/weight ratio, and longer mechanical ventilation were associated with time-to-death >90 days after receiving MBTS. Larger shunt size/weight ratio should be reevaluated within 90 days to minimize the risk of shunt over flow.
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Kim ER, Lee CH, Kim WH, Lim JH, Kim YJ, Min J, Cho S, Kwak JG. Primary Versus Staged Repair in Neonates With Pulmonary Atresia and Ventricular Septal Defect. Ann Thorac Surg 2020; 112:825-830. [PMID: 32896547 DOI: 10.1016/j.athoracsur.2020.06.098] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2020] [Revised: 06/16/2020] [Accepted: 06/23/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND The 2 surgical strategies for neonates with ductal-dependent pulmonary atresia and ventricular septal defect are primary biventricular repair (BVR) or initial palliation with a modified Blalock-Taussig shunt (BTS) followed by second stage repair. In this study, we report the combined outcomes from 2 hospitals using different strategies. METHODS Between 2004 and 2017, 66 neonates underwent surgery with palliative shunts (BTS group: n = 30, 45.5%) or primary biventricular repair (pBVR group: n = 36, 54.5%). The 2 groups were similar in age, body weight, and Nakata index scores. The overall mean follow-up duration was 7.51 ± 4.35 years, and early and late results were compared between the groups. RESULTS The 10-year overall survival was 84.8% (94.4% for pBVR vs 75.7% for BTS, P = .032). The BTS group had 2 early and 6 interstage mortalities, and the pBVR group had no early and 2 late mortalities. In the BTS group, the Nakata index score significantly increased during the interstage period (P < .001). In univariable analysis, genetic or extracardiac anomalies were a risk factor for mortality (hazard ratio, 5.56; P = .038). After achieving BVR, the pBVR group underwent significantly more frequent right ventricle outflow tract reinterventions (P < .001) at a much earlier period (P = .017) compared with the BTS group. CONCLUSIONS In neonates with ductal-dependent pulmonary atresia and ventricular septal defect, the primary BVR approach provides an excellent survival rate, but the burden of right ventricle outflow tract reintervention is heavy. The staged approach with BTS promotes pulmonary artery growth, but hospital and interstage mortality are significant. Genetic and extracardiac anomalies are significant risk factors for mortality.
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Affiliation(s)
- Eung Re Kim
- Department of Thoracic and Cardiovascular Surgery, Sejong General Hospital, Bucheon-si, Gyeonggi-do, Republic of Korea.
| | - Chang-Ha Lee
- Department of Thoracic and Cardiovascular Surgery, Sejong General Hospital, Bucheon-si, Gyeonggi-do, Republic of Korea
| | - Woong-Han Kim
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Children's Hospital, Seoul, Republic of Korea
| | - Jae Hong Lim
- Department of Thoracic and Cardiovascular Surgery, Sejong General Hospital, Bucheon-si, Gyeonggi-do, Republic of Korea
| | - Yong-Jin Kim
- Department of Thoracic and Cardiovascular Surgery, Sejong General Hospital, Bucheon-si, Gyeonggi-do, Republic of Korea
| | - Jooncheol Min
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Children's Hospital, Seoul, Republic of Korea
| | - Sungkyu Cho
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Children's Hospital, Seoul, Republic of Korea
| | - Jae Gun Kwak
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Children's Hospital, Seoul, Republic of Korea
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Neonatal Pulmonary Atresia With Intact Ventricular Septum-8-Year Surgical Experience at One Center. J Surg Res 2020; 251:38-46. [PMID: 32113036 DOI: 10.1016/j.jss.2020.01.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 01/23/2020] [Accepted: 01/25/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND Surgical treatment of pulmonary atresia with intact ventricular septum (PA/IVS) in neonates is challenging because of the broad variations of right ventricular (RV) malformations. In this retrospective study, we summarized our 8-y experience in surgical management for neonatal PA/IVS patients. METHODS Thirty-four neonates with PA/IVS between July 1, 2006 and June 30, 2014, were reviewed. Patients were categorized into three groups: mild, moderate, and severe RV hypoplasia according to RV morphology and development. Patients were on regular follow-up for at least 5 y. Overall survival, complications, reinterventions, risk factors for mortality, and health status were evaluated. RESULTS 21 patients (61.8%) were treated with biventricular repair, eight patients (23.5%) with Fontan procedure, and one patient (2.9%) with bidirectional Glenn procedure. There were four postprocedural mortalities and one late death. The 5-y survival rates after final surgical repair for mild, moderate, and severe RV hypoplasia groups were 100%, 100%, and 88.9%, respectively. The reintervention rates were 0% (0/4), 21.4% (3/14), and 55.6% (5/9) for the subgroups, respectively. At the latest follow-up, most patients had a status characterized as New York Heart Association class I (88.9%, 24/27). CONCLUSIONS Surgical management for PA/IVS in neonates should be individualized. Favorable early and long-term outcomes can be achieved in neonatal PA/IVS patients by individualized surgical strategies, regardless of the degree of RV hypoplasia. In spite of potential RV catch-up development, the degree of RV hypoplasia is a factor of paramount importance to assess PA/IVS in neonates.
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Determinants of acute events leading to mortality after shunt procedure in univentricular palliation. J Thorac Cardiovasc Surg 2019; 158:1144-1153.e6. [DOI: 10.1016/j.jtcvs.2019.03.126] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2018] [Revised: 03/26/2019] [Accepted: 03/30/2019] [Indexed: 12/31/2022]
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Wright LK, Knight JH, Thomas AS, Oster ME, St Louis JD, Kochilas LK. Long-term outcomes after intervention for pulmonary atresia with intact ventricular septum. Heart 2019; 105:1007-1013. [PMID: 30712000 DOI: 10.1136/heartjnl-2018-314124] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Revised: 12/14/2018] [Accepted: 12/19/2018] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE Pulmonary atresia with intact ventricular septum (PA/IVS) can be treated by various operative and catheter-based interventions. We aim to understand the long-term transplant-free survival of patients with PA/IVS by treatment strategy. METHODS Cohort study from the Pediatric Cardiac Care Consortium, a multi-institutional registry with prospectively acquired outcome data after linkage with the National Death Index and the Organ Procurement and Transplantation Network. RESULTS Eligible patients underwent neonatal surgery or catheter-based intervention for PA/IVS between 1982 and 2003 (median follow-up of 16.7 years, IQR: 12.6-22.7). Over the study period, 616 patients with PA/IVS underwent one of three initial interventions: aortopulmonary shunt, right ventricular decompression or both. Risk factors for death at initial intervention included earlier birth era (1982-1992), chromosomal abnormality and atresia of one or both coronary ostia. Among survivors of neonatal hospitalisation (n=491), there were 99 deaths (4 post-transplant) and 10 transplants (median age of death or transplant 0.7 years, IQR: 0.3-1.8 years). Definite repair or last-stage palliation was achieved in the form of completed two-ventricle repair (n=201), one-and-a-half ventricle (n=39) or Fontan (n=96). Overall 20-year survival was 66%, but for patients discharged alive after definitive repair, it reached 97.6% for single-ventricle patients, 90.9% for those with one-and-a-half ventricle and 98.0% for those with complete two-ventricle repair (log-rank p=0.052). CONCLUSIONS Transplant-free survival in PA/IVS is poor due to significant infantile and interstage mortality. Survival into early adulthood is excellent for patients reaching completion of their intended path independent of type of repair.
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Affiliation(s)
- Lydia K Wright
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA.,Sibley Heart Center, Children's Healthcare of Atlanta, Atlanta, GA
| | - Jessica H Knight
- Department of Epidemiology and Biostatistics, University of Georgia School of Public Health, Athens, GA
| | - Amanda S Thomas
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Matthew E Oster
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA.,Sibley Heart Center, Children's Healthcare of Atlanta, Atlanta, GA
| | - James D St Louis
- Department of Pediatric Surgery, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri, USA
| | - Lazaros K Kochilas
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA.,Sibley Heart Center, Children's Healthcare of Atlanta, Atlanta, GA
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Şişli E, Tuncer ON, Şenkaya S, Doğan E, Şahin H, Ayık MF, Atay Y. Blalock-Taussig Shunt Size: Should it be Based on Body Weight or Target Branch Pulmonary Artery Size? Pediatr Cardiol 2019; 40:38-44. [PMID: 30121861 DOI: 10.1007/s00246-018-1958-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2018] [Accepted: 08/09/2018] [Indexed: 12/28/2022]
Abstract
The study aimed to revisit the in-hospital predictors of shunt thrombosis (ST) in the foreground of the pulmonary artery size in patients who received modified Blalock-Taussig shunt (mBTS) as the first-stage palliation. Data from 80 patients who received mBTS as their initial palliative procedure between February 2012 and January 2017 was retrospectively collected. The median age and weight of the patients at the time of their mBTS procedure was 4 days (IQR 2-22 days) and 3.2 kg (IQR 2.8-3.7 kg), respectively. Of the 80 patients in the study, 11 (13.8%) developed ST. The diameter and corresponding z scores of the pulmonary arteries were significantly lower in patients with ST. The median shunt size/shunted pulmonary artery size (S/PA) ratio was considerably higher in patients with ST. In logistic regression analysis, pulmonary artery hypoplasia (PAH) [odds ratio (OR) = 13.7 (0.06-0.21), p < 0.001], S/PA ratio ≥ 0.9 [OR = 8.1 (0.03-0.53), p = 0.03], prematurity [OR = 9.5 (0.05-0.33), p = 0.003], and shunt size/weight (S/W) ratio ≥ 1.3 [OR = 6.4 (0.04-0.67), p = 0.012] were found to have a significant impact on ST. The best combination of sensitivity and specificity of the S/W (0.73 and 0.75) and the S/PA ratio (0.73 and 0.80) were achieved at the cut-off value of 1.3 and 0.9, respectively. The Youden index of S/PA was 0.52. While the area under the curve (AUC) of the S/W ratio was 0.686 ± 0.12 (p = 0.049), the AUC of the S/PA ratio was 0.791 ± 0.08 (p = 0.002). In conclusion, instead of weight, considering the size of the target pulmonary artery and thereby, the S/PA ratio would be more instructive in determining shunt size. There were a high number of patients in our study who showed PAH having received a shunt size based on their body weight. By contrast, our results showed that the S/PA ratio of ≥ 0.9 would be a good predictor of in-hospital ST.
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Affiliation(s)
- Emrah Şişli
- Departments of Pediatric Cardiovascular Surgery, Ege University Faculty of Medicine, Izmir, Turkey. .,Section of Pediatric Cardiovascular Surgery, Department of Cardiovasular Surgery, Ege University Faculty of Medicine, Kazım Dirik District, Üniversite Street, 35140, Bornova, Izmir, Turkey.
| | - Osman Nuri Tuncer
- Departments of Pediatric Cardiovascular Surgery, Ege University Faculty of Medicine, Izmir, Turkey
| | - Suat Şenkaya
- Cardiovascular Surgery, Ege University Faculty of Medicine, Izmir, Turkey
| | - Eser Doğan
- Pediatric Cardiology, Ege University Faculty of Medicine, Izmir, Turkey
| | - Hatice Şahin
- Medical Education, Ege University Faculty of Medicine, Izmir, Turkey
| | - Mehmet Fatih Ayık
- Departments of Pediatric Cardiovascular Surgery, Ege University Faculty of Medicine, Izmir, Turkey
| | - Yüksel Atay
- Departments of Pediatric Cardiovascular Surgery, Ege University Faculty of Medicine, Izmir, Turkey
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Safety of outpatient cardiac catheterisation in infants with single-ventricle or shunt-dependent biventricular congenital heart disease. Cardiol Young 2018; 28:1444-1451. [PMID: 30309401 DOI: 10.1017/s1047951118001567] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE We aimed to investigate the incidence and causes of readmission of infants with single-ventricle and shunt-dependent biventricular CHD following routine, outpatient cardiac catheterisation. BACKGROUND Cardiac catheterisation is commonly performed in patients with single-ventricle and shunt-dependent biventricular CHD for haemodynamic assessment and surgical planning. Best practices for post-procedural care in this population are unknown, and substantial variation exists between centres. Outpatient catheterisation reduces parental anxiety and decreases cost. Our institutional strategy is to discharge patients following a 4- to 6-hour post-procedure observation period. METHODS Retrospective cohort study using the Society of Thoracic Surgeons Database identified patients 23 hours. There were no differences in baseline characteristics between discharged and admitted patients. Patients who underwent intervention were more likely to be admitted. Patients with hypoplastic left heart syndrome did not have major adverse events or readmissions. No intra- or peri-procedural deaths occurred. CONCLUSIONS Outpatient cardiac catheterisation may be a safe option for infants with single-ventricle and shunt-dependent biventricular CHD, with low readmission rates and minimal morbidity.
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Wiggins LM, Wells WJ, Starnes VA, Kumar RS. Simultaneous Systemic to Pulmonary Shunt and Pulmonary Artery Banding is a Viable Option for Neonatal Palliation of Single Ventricle Physiology. Semin Thorac Cardiovasc Surg 2018; 31:234-241. [PMID: 30278269 DOI: 10.1053/j.semtcvs.2018.09.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Accepted: 09/21/2018] [Indexed: 11/11/2022]
Abstract
A subset of neonates with single ventricle (SV) physiology has antegrade pulmonary blood flow that is deemed unlikely to be reliable until Glenn. We have used systemic to pulmonary shunt (SPS) with pulmonary artery banding (PAB) to optimize pulmonary blood flow while maintaining reserve antegrade flow. We hypothesize that this is an effective strategy that can be accomplished without the routine need for cardiopulmonary bypass. We retrospectively reviewed the records of 60 neonates who underwent combined SPS + PAB between 2004 and 2015. Data are presented as median with quartiles. Children were 8 (4-19) days old at surgery and included 38 (63%) boys. Atresia or severe stenosis of the subpulmonary atrioventricular (AV) valve associated with pulmonary blood flow across a bulboventricular foramen was present in 37 (62%). In 20 (33%), heterotaxy-associated unbalanced AV canal with pulmonary stenosis with or without anomalous pulmonary venous drainage was present. First-stage palliation was accomplished without cardiopulmonary bypass in 44 patients (73%). There were 7 (12%) hospital deaths, 4 among the 20 (20%) with heterotaxy. Fifty-three children were followed for a median 5.1 (1.8-8.2) years. Three early reinterventions were required after initial palliation (1 PAB adjustment, 2 SPS balloon angioplasties). Five additional heterotaxy patients experienced late mortality during follow-up. There were no early or emergent Glenn. Thirty-nine patients have reached Fontan circulation with a median pre-Fontan PA pressure of 14 (12-18) mm Hg. One patient converted to biventricular physiology and the remaining await completion Fontan. Heterotaxy was the only independent predictor of mortality (hazard ratio 10 (2.3-44, P < 0.001). In SV patients with unreliable antegrade PA flow, SPS + PAB is an effective first-stage palliation. SV patients with heterotaxy are at increased risk for mortality.
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Affiliation(s)
- Luke M Wiggins
- Heart Institute, Children's Hospital Los Angeles, Keck School of Medicine of the University of Southern California, Los Angeles, California; Division of Cardiac Surgery, Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Winfield J Wells
- Heart Institute, Children's Hospital Los Angeles, Keck School of Medicine of the University of Southern California, Los Angeles, California; Division of Cardiac Surgery, Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Vaughn A Starnes
- Heart Institute, Children's Hospital Los Angeles, Keck School of Medicine of the University of Southern California, Los Angeles, California; Division of Cardiac Surgery, Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Ram S Kumar
- Heart Institute, Children's Hospital Los Angeles, Keck School of Medicine of the University of Southern California, Los Angeles, California; Division of Cardiac Surgery, Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California; Department of Pediatrics, Keck School of Medicine of the University of Southern California, Los Angeles, California.
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Risk Factors for Failure of Systemic-to-Pulmonary Artery Shunts in Biventricular Circulation. Pediatr Cardiol 2018; 39:1323-1329. [PMID: 29756161 DOI: 10.1007/s00246-018-1898-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2018] [Accepted: 05/08/2018] [Indexed: 02/07/2023]
Abstract
Systemic-to-pulmonary artery shunt placement is an established palliative procedure for congenital heart disease, but it is associated with high morbidity and mortality. Data of all patients with biventricular circulation who underwent systemic-to-pulmonary artery shunt implantation between 2000 and 2016 were reviewed. Endpoints of the study were shunt failure and shunt-related mortality. Shunt failure was defined as any shunt dysfunction requiring intervention or reoperation. Shunt-related mortality was defined as death due to shunt dysfunction. A total of 217 shunts (central shunt, n = 131, Blalock-Taussig shunt, n = 86) were implanted in 178 patients. The median age of the patients was 98 days [1 day to 1.2 years]. Corrective surgery was performed at a median time of 0.6 years [3 months to 7 years] after shunt placement. Shunt failure was diagnosed in 21 patients (9.6%) at a median time of 14.6 days [0 days to 2 years]. Causes of shunt failure were stenosis (n = 11; 5%) and thrombosis (n = 10; 4.6%). The rate of freedom from shunt failure was 89.9 ± 2.6% at 1 year, the rate of shunt-related mortality was 3% (n = 5), and the rate of freedom from shunt-related mortality at 1 year was 97.5 ± 1%. Platelet transfusion was required in 43 patients (20%), all for postoperative thrombocytopenia. Perioperative platelet transfusion (p = 0.03) and shunt size of 3 mm (p = 0.03) were identified as risk factors for shunt failure. Shunt size of 3 mm was also identified as a risk factor for shunt-related mortality. The ideal shunt size in patients with biventricular circulation requiring a systemic-to-pulmonary artery shunt is 3.5 mm or larger. Platelet transfusion increases the risk of shunt failure and should be avoided. Type of shunt and diagnosis have no influence on morbidity or mortality after shunt placement.
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Major Adverse Events Following Over-Shunting Are Associated With Worse Outcomes Than Major Adverse Events After a Blocked Systemic-to-Pulmonary Artery Shunt Procedure. Pediatr Crit Care Med 2018; 19:854-860. [PMID: 30024573 DOI: 10.1097/pcc.0000000000001659] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVES Causes of major adverse event after systemic-to-pulmonary shunt procedure are usually shunt occlusion or over-shunting. Outcomes categorized on the basis of these causes will be helpful both for quality improvement and prognostication. DESIGN Retrospective cohort analysis of children who underwent a systemic-to-pulmonary shunt after excluding those who had it for Norwood or Damus-Kaye-Stansel procedure. SETTING The Royal Children's Hospital, Melbourne, VIC, Australia. PATIENTS From 2008 to 2015, 201 children who had a systemic-to-pulmonary shunt were included. INTERVENTIONS Major adverse event is defined as one or more of cardiac arrest, chest reopening, or requirement for extracorporeal membrane oxygenation. Study outcome is a "composite poor outcome," defined as one or more of acute kidney injury, necrotizing enterocolitis, brain injury, or in-hospital mortality. MEASUREMENTS AND MAIN RESULTS Median (interquartile range) age was 12 days (6-38 d) and median (interquartile range) time to major adverse event was 5.5 hours (2-17 hr) after admission. Overall, 36 (18%) experienced a major adverse event, and reasons were over-shunting (n = 17), blocked shunt (n = 13), or other (n = 6). Fifteen (88%) in over-shunting group suffered a cardiac arrest compared with two (15%) in the blocked shunt group (p < 0.001). The composite poor outcome was seen in 15 (88%) in over-shunting group, four (31%) in the blocked shunt group, and 56 (34%) in those who did not experience a major adverse event (p < 0.001). By multivariable analysis, predictors for composite poor outcome were major adverse event due to over-shunting (no major adverse event-reference; over-shunting odds ratio, 18.60; 95% CI, 3.87-89.4 and shunt-block odds ratio, 1.57; 95% CI, 0.46-5.35), single ventricle physiology (odds ratio, 4.70; 95% CI, 2.34-9.45), and gestation (odds ratio, 0.84/wk increase; 95% CI, 0.74-0.96). CONCLUSIONS Infants who suffer major adverse event due to over-shunting experience considerably poorer outcomes than those who experience events due to shunt block. A mainly hypoxic event with maintenance of systemic perfusion (as often seen in a blocked shunt) is less likely to result in poorer outcomes than those after a hypoxic-ischemic event (commonly seen in over-shunting).
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20
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Patregnani JT, Sochet AA, Zurakowski D, Klugman D, Diab Y, Berger JT, Sinha P. Cardiopulmonary Bypass Reduces Early Thrombosis of Systemic-to-Pulmonary Artery Shunts. World J Pediatr Congenit Heart Surg 2018; 9:276-282. [PMID: 29692234 DOI: 10.1177/2150135118755985] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Shunt thrombosis is a significant cause of morbidity and mortality after systemic-to-pulmonary artery shunt (SPS) placement. Concurrent procedures with placement of SPS may require cardiopulmonary bypass (CPB). Cardiopulmonary bypass is known to cause bleeding and platelet dysfunction in infants, which may protect from early shunt thrombosis. We hypothesized that infants undergoing SPS placement on CPB have a lower incidence of early shunt thrombosis. METHODS Retrospective cohort study of infants undergoing SPS placement from January 2008 to December 2014 was performed. Patients with and without early shunt thrombosis and on or off CPB were compared using the Mann-Whitney U test or Fisher exact test. Multivariable regression analysis was performed to identify independent predictors of early shunt thrombosis and to assess effect of CPB independent of other factors. RESULTS Seventy-five infants underwent SPS placement during the study period (on CPB, n = 25; off CPB, n = 50). Operative mortality was 11% (8/75). Nine (12%) patients developed early shunt thrombosis, all of whom had shunt placement off CPB. Independent risk factors for early shunt thrombosis were identified to be SPS placement off CPB ( P = .011), prematurity ( P = .034), and competitive antegrade pulmonary blood flow ( P = .038). CONCLUSION Prematurity, competitive antegrade pulmonary blood flow, and shunt placement off CPB lead to higher risk of early shunt thrombosis. We speculate that the protection offered by use of CPB may be accounted for by the associated complex coagulopathy and platelet dysfunction associated with CPB.
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Affiliation(s)
- Jason T Patregnani
- 1 Division of Cardiac Intensive Care Medicine, Children's National Health System, The George Washington School of Medicine, Washington, DC, USA
| | - Anthony A Sochet
- 2 Division of Critical Care Medicine, Johns Hopkins All Children's Hospital, Johns Hopkins University, St Petersburg, FL, USA
| | - David Zurakowski
- 3 Department of Anesthesia, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.,4 Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Darren Klugman
- 1 Division of Cardiac Intensive Care Medicine, Children's National Health System, The George Washington School of Medicine, Washington, DC, USA
| | - Yaser Diab
- 5 Division of Hematology/Oncology, Children's National Health System, The George Washington School of Medicine, Washington, DC, USA
| | - John T Berger
- 1 Division of Cardiac Intensive Care Medicine, Children's National Health System, The George Washington School of Medicine, Washington, DC, USA
| | - Pranava Sinha
- 6 Division of Cardiovascular Surgery, Children's National Health System, The George Washington School of Medicine, Washington, DC, USA
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Ambarsari YA, Purbojo A, Blumauer R, Glöckler M, Toka O, Cesnjevar RA, Rüffer A. Systemic-to-pulmonary artery shunting using heparin-bonded grafts. Interact Cardiovasc Thorac Surg 2018; 27:591-597. [DOI: 10.1093/icvts/ivy100] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Accepted: 03/04/2018] [Indexed: 12/17/2022] Open
Affiliation(s)
- Yuletta Adny Ambarsari
- Department of Pediatric Cardiac Surgery, University-Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Ariawan Purbojo
- Department of Pediatric Cardiac Surgery, University-Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Robert Blumauer
- Department of Pediatric Cardiac Surgery, University-Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Martin Glöckler
- Department of Pediatric Cardiology, University-Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Okan Toka
- Department of Pediatric Cardiology, University-Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Robert A Cesnjevar
- Department of Pediatric Cardiac Surgery, University-Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - André Rüffer
- Department of Pediatric Cardiac Surgery, University-Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
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Hobbes B, d’Udekem Y, Zannino D, Konstantinov IE, Brizard C, Brink J. Determinants of Adverse Outcomes After Systemic-To-Pulmonary Shunts in Biventricular Circulation. Ann Thorac Surg 2017; 104:1365-1370. [DOI: 10.1016/j.athoracsur.2017.06.043] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2017] [Revised: 06/08/2017] [Accepted: 06/12/2017] [Indexed: 10/18/2022]
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Sasikumar N, Hermuzi A, Fan CPS, Lee KJ, Chaturvedi R, Hickey E, Honjo O, Van Arsdell GS, Caldarone CA, Agarwal A, Benson L. Outcomes of Blalock-Taussig shunts in current era: A single center experience. CONGENIT HEART DIS 2017; 12:808-814. [PMID: 28736841 DOI: 10.1111/chd.12516] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Revised: 06/20/2017] [Accepted: 06/27/2017] [Indexed: 12/26/2022]
Abstract
OBJECTIVES Mortality associated with the modified Blalock-Taussig shunt (MBTS) remains high despite advanced perioperative management. This study was formulated to provide data on (1) current indications, (2) outcomes, and (3) factors affecting mortality and morbidity. DESIGN A retrospective single center chart review identified 95 children (excluding hypoplastic left heart lesions) requiring a MBTS. Mortality and major morbidity were analyzed using the Kaplan Meier method and risk factor analysis using Cox's proportional hazard regression. RESULTS Median age was 8 (0-126) days, weight 3.1(1.7-5.4) kg. Seventy-three percent were neonates, 58% duct dependent and 73% had single ventricle physiology. Ninety-seven percent had a sternotomy approach for shunt placement with 70% receiving a 3.5 mm graft. Mean graft index (shunt cross sectional area [mm2 ]/BSA [m2 ]) was 44.39 ± 8.04 and shunt size (mm) to body weight (kg) ratio 1.1 ± 0.2. Hospital mortality was 12%, with an interval mortality of 6%. Shunt thrombosis/stenosis occurred in 23% and pulmonary over circulation in 30%, while shunt reoperation was required in 12% and catheter intervention in 8% of the cohort. At 1-year, survival was 82.0% (95% CI [72.7%, 88.4%]), and survival free of major morbidity 61.4% (95% CI [50.7%, 70.5%]). Duct dependency predisposed to mortality (P = .01, HR 6.74 [1.54, 29.53]) and composite outcome (mortality and major morbidity) (P = .04, HR 2.15, CI [1.036, 4.466]) and higher graft index to mortality (P = .005, HR 1.07 [1.02, 1.12]). CONCLUSIONS The commonest indication for a MBTS in the current era was single ventricle palliation. Morbidity and mortality was considerable, partly explained by the higher at risk population. Alternative methods to maintain pulmonary blood flow in place of a MBTS requires further investigation.
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Affiliation(s)
- Navaneetha Sasikumar
- Department of Pediatrics, The Labatt Family Heart Center, Division of Cardiology, The University of Toronto School of Medicine, Toronto, Canada
| | - Antony Hermuzi
- Department of Pediatrics, The Labatt Family Heart Center, Division of Cardiology, The University of Toronto School of Medicine, Toronto, Canada
| | - Chun-Po Steve Fan
- Department of Pediatrics, The Labatt Family Heart Center, Division of Cardiology, The University of Toronto School of Medicine, Toronto, Canada
| | - Kyong-Jin Lee
- Department of Pediatrics, The Labatt Family Heart Center, Division of Cardiology, The University of Toronto School of Medicine, Toronto, Canada
| | - Rajiv Chaturvedi
- Department of Pediatrics, The Labatt Family Heart Center, Division of Cardiology, The University of Toronto School of Medicine, Toronto, Canada
| | - Edward Hickey
- Department of Pediatrics, The Labatt Family Heart Center, Division of Cardiology, The University of Toronto School of Medicine, Toronto, Canada
| | - Osami Honjo
- Department of Pediatrics, The Labatt Family Heart Center, Division of Cardiology, The University of Toronto School of Medicine, Toronto, Canada
| | - Glen S Van Arsdell
- Department of Pediatrics, The Labatt Family Heart Center, Division of Cardiology, The University of Toronto School of Medicine, Toronto, Canada
| | - Christopher A Caldarone
- Department of Pediatrics, The Labatt Family Heart Center, Division of Cardiology, The University of Toronto School of Medicine, Toronto, Canada
| | - Arnav Agarwal
- Department of Pediatrics, The Labatt Family Heart Center, Division of Cardiology, The University of Toronto School of Medicine, Toronto, Canada
| | - Lee Benson
- Department of Pediatrics, The Labatt Family Heart Center, Division of Cardiology, The University of Toronto School of Medicine, Toronto, Canada
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Rames JD, Kavarana MN, Schoepf UJ, Hlavacek AM. The utility of computed tomographic angiography in a neonate on extracorporeal membrane oxygenation with extreme cyanosis after Blalock-Taussig shunt. Ann Pediatr Cardiol 2017; 10:209-211. [PMID: 28566834 PMCID: PMC5431038 DOI: 10.4103/0974-2069.205137] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A modified Blalock-Taussig shunt (mBTS) is often employed to provide pulmonary blood flow in neonates that are born with cyanotic congenital heart defects. However, acute shunt thrombosis can occur in the postoperative period, resulting in profound cyanosis. In this case report, we describe the utility of computed tomographic angiography (CTA) in the management of a neonate with extreme cyanosis after placement of a mBTS while on extracorporeal membrane oxygenation. Using CTA, several small clots were identified in the shunt as well as stenosis of the left pulmonary artery; neither of which were identified with echocardiography. The CTA allowed for quick identification of the disorder and helped direct prompt surgical intervention.
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Affiliation(s)
- Jess D Rames
- Department of Radiology and Radiological Science, Division of Cardiovascular Imaging, Medical University of South Carolina, Charleston, SC, USA
| | - Minoo N Kavarana
- Department of Surgery, Division of Pediatric Cardiac Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - U Joseph Schoepf
- Department of Radiology and Radiological Science, Division of Cardiovascular Imaging, Medical University of South Carolina, Charleston, SC, USA.,Department of Medicine, Medical University of South Carolina, Charleston, SC, USA.,Department of Pediatrics, Division of Pediatric Cardiology, Medical University of South Carolina, Charleston, SC, USA
| | - Anthony Marcus Hlavacek
- Department of Radiology and Radiological Science, Division of Cardiovascular Imaging, Medical University of South Carolina, Charleston, SC, USA.,Department of Pediatrics, Division of Pediatric Cardiology, Medical University of South Carolina, Charleston, SC, USA
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Chittithavorn V, Duangpakdee P, Rergkliang C, Pruekprasert N. Risk factors for in-hospital shunt thrombosis and mortality in patients weighing less than 3 kg with functionally univentricular heart undergoing a modified Blalock–Taussig shunt†. Interact Cardiovasc Thorac Surg 2017; 25:407-413. [DOI: 10.1093/icvts/ivx147] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Accepted: 04/14/2017] [Indexed: 12/13/2022] Open
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Agarwal A, Firdouse M, Brar N, Yang A, Lambiris P, Chan AK, Mondal TK. Incidence and Management of Thrombotic and Thromboembolic Complications Following the Norwood Procedure: A Systematic Review. Clin Appl Thromb Hemost 2016; 23:911-921. [DOI: 10.1177/1076029616679506] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Background: The stage 1 Norwood procedure and its variants represent the first step of palliation for hypoplastic left heart syndrome. Although appropriate postoperative thromboprophylaxis is integral, significant variance remains across institutional practices. The purpose of this systematic review is to estimate the incidence of thrombosis and thromboembolism following the Norwood or modified Blalock-Taussig shunt procedure and examine current thromboprophylaxis regimens. Methods: Ovid MEDLINE and Embase were searched from January 2000 to June 2016 for primary studies explicitly reporting incidence of thrombosis, thromboembolism (strokes and pulmonary embolisms), or shunt occlusion in neonates, infants, and children undergoing the Norwood procedure or any variant. All-cause mortality was a secondary outcome of interest. Results: Of 887 identified articles, 15 cohort studies were deemed eligible, the majority including modified Blalock-Taussig shunt patients. Reported incidence of thrombosis ranged from 0% to 40%; thromboembolic events were rarely reported. Overall mortality ranged from 4.5% to 31.3% across studies. Although most studies involved the long-term acetylsalicylic acid use, thromboprophylaxis strategies varied across studies. Due to substantial variability in event rates, no correlation was identified with thrombotic complications. Discussion: Clinical practice guidelines recommend that patients receive intraoperative unfractionated heparin therapy and either aspirin or no antithrombotic therapy postoperatively. Our findings suggest a substantial risk of thrombosis and thromboembolism and demonstrate substantial variation in thromboprophylaxis practices. Conclusion: Although postoperative thromboprophylaxis seems optimal, it remains controversial whether the long-term aspirin use is most effective. Our findings highlight the lack of a gold-standard thromboprophylaxis strategy and emphasize the need for more consistency.
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Affiliation(s)
- Arnav Agarwal
- Department of Pediatrics, McMaster Children’s Hospital, McMaster University, Hamilton, Ontario, Canada
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Mohammed Firdouse
- Department of Pediatrics, McMaster Children’s Hospital, McMaster University, Hamilton, Ontario, Canada
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Nishaan Brar
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Andy Yang
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Panos Lambiris
- University Health Network Library and Information Services, Toronto General Hospital, Toronto, Ontario, Canada
| | - Anthony K. Chan
- Department of Pediatrics, McMaster Children’s Hospital, McMaster University, Hamilton, Ontario, Canada
| | - Tapas K. Mondal
- Department of Pediatrics, McMaster Children’s Hospital, McMaster University, Hamilton, Ontario, Canada
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Alsoufi B, Gillespie S, Mori M, Clabby M, Kanter K, Kogon B. Factors affecting death and progression towards next stage following modified Blalock-Taussig shunt in neonates. Eur J Cardiothorac Surg 2016; 50:169-77. [DOI: 10.1093/ejcts/ezw017] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Accepted: 12/29/2015] [Indexed: 12/13/2022] Open
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Dorobantu DM, Pandey R, Sharabiani MT, Mahani AS, Angelini GD, Martin RP, Stoica SC. Indications and results of systemic to pulmonary shunts: results from a national database. Eur J Cardiothorac Surg 2016; 49:1553-63. [DOI: 10.1093/ejcts/ezv435] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2015] [Accepted: 11/17/2015] [Indexed: 11/14/2022] Open
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