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Ann Thorac Surg 1998;66:512-517
© 1998 The Society of Thoracic Surgeons

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Original articles: cardiovascular

Effects of modified and classic Blalock-Taussig shunts on the pulmonary arterial tree

^a Department of Paediatric Cardiology, Guy’s Hospital, London, England, United Kingdom

Accepted for publication March 10, 1998.

Address reprint requests to Dr Qureshi, Department of Paediatric Cardiology, Guy’s Hospital, St. Thomas St, London SE1 9RT, England

	Abstract

Top Footnotes Abstract Introduction Material and methods Results Comment References

 
Background. The aim of this study was to assess by angiography the late effects of both classic and modified Blalock-Taussig shunts in terms of growth and development of stenosis and distortion.

Methods. At a mean of 51 months postoperatively, we retrospectively reviewed the results in 78 patients who underwent creation of Blalock-Taussig shunts (25 classic and 71 modified).

Results. At the level of the anastomosis, the shunt caused a reduction in diameter of the pulmonary artery in 49% of all shunts, major stenosis (>50% narrowing of the lumen) in 14%, and distortion of the pulmonary artery in 19%, findings that did not correlate with the type of shunt. Distortion did correlate with younger age at the time of shunt operation (p = 0.01).

Conclusions. After a Blalock-Taussig shunt, growth of the pulmonary arteries occurred but did not exceed the normal growth of the pulmonary arterial tree. Moreover, a shunt procedure can cause distortion and stenosis of the pulmonary artery, which may have important implications for future corrective surgical intervention. All these findings support earlier complete surgical repair of correctable congenital cardiac defects.

	Introduction

Top Footnotes Abstract Introduction Material and methods Results Comment References

 
Surgical palliation for neonates and children with diminished pulmonary artery blood flow is usually accomplished with systemic–pulmonary artery shunts. Despite the recent enthusiasm for primary repair of many cyanotic heart defects at a young age, palliative shunt procedures still play an important role in the treatment of some critically ill patients. The shunts improve tissue oxygenation and may promote normal and symmetric development of the pulmonary arteries [1–5]. However, the effects of the shunts on the pulmonary arteries remain controversial, especially in regard to distortion, stenosis, and asymmetric growth of the arteries [6–10]. We undertook a retrospective study to assess the late effects of both classic and modified Blalock-Taussig shunts on the pulmonary arterial tree with particular reference to growth and development of stenoses and distortion of the pulmonary arteries at the shunt anastomoses. The assessments were done using postoperative angiograms.

	Material and methods

Top Footnotes Abstract Introduction Material and methods Results Comment References

 
We retrospectively reviewed the cases of 78 patients who had a Blalock-Taussig shunt procedure between 1980 and 1992 and for whom angiograms were available after shunt implantation. A further 22 patients underwent creation of a Blalock-Taussig shunt (19 modified and three classic shunts) during the same period, but post-operative angiography was not performed; these patients were excluded from the present study. Of the 19 with a modified shunt, 2 died suddenly (1 had a 5-mm shunt and 1, a 6-mm shunt), but no postmortem examination was done. Eighteen of the 78 patients received a second systemic–pulmonary artery shunt. Thus, a total of 96 Blalock-Taussig shunts (71 modified and 25 classic shunts) were studied. Ten patients received both a classic and a modified shunt, 7 had two modified shunts, and 1 patient had two classic shunts.

Operative technique
The chest was entered through either a left or a right lateral thoracotomy in the fourth intercostal space. The classic Blalock-Taussig shunt was constructed by standard surgical techniques between the ends of the transected subclavian artery and the side of the pulmonary artery. Thirteen classic shunts were constructed on the side opposite to and 12 on the same side as the aortic arch. Modified Blalock-Taussig shunts were constructed using polytetrafluoroethylene (Gore-Tex) grafts interposed between the undivided subclavian artery and the pulmonary artery as described by de Leval and associates [1]. The size of the graft was chosen by the operating surgeons on the basis of the size of the pulmonary and subclavian arteries. All the anastomoses were performed with 6-0 or 7-0 synthetic suture material (Prolene; Ethicon). Classic shunts were anastomosed with an interrupted suture technique and modified shunts, a continuous suture technique. Construction of the shunts was performed with the patient heparinized, and heparin sodium was not reversed at the end of the procedure. Only 3 of the patients received antiplatelet agents after the operation. The choice between a classic and a modified shunt was related to the time of operation; most classic shunts were constructed in the early 1980s.

Patient data
Sixty-three of the 78 patients received 71 modified shunts; 16 were 4 mm in diameter; 29, 5 mm in diameter; and 26, 6 mm in diameter. Age at operation ranged from 1 day to 164 months (mean age, 20 months). Thirty-four patients (44%) were operated on in the first month of life on an emergency basis. Weight at operation ranged from 2.1 to 31.8 kg (median weight, 7.9 kg). The mean preoperative hemoglobin level was 15.8 ± 0.25 g/dL (range, 10.3 to 22.5 g/dL), and the mean albumin level was 3.8 ± 0.6 g/dL (range, 2.0 to 4.9 g/dL). The cardiac abnormalities for which shunts were performed were as follows: tetralogy of Fallot in 22 patients (28%), pulmonary atresia with ventricular septal defect in 14 (18%), pulmonary atresia with intact ventricular septum in 7 (9%), double-outlet right ventricle with pulmonary stenosis in 9 (12%) or with pulmonary atresia in 5 (6%), tricuspid atresia with ventricular septal defect and pulmonary stenosis in 12 (15%), tricuspid atresia with intact ventricular septum and pulmonary atresia in 2 (3%), and other defects combining pulmonary stenosis and transposition of the great arteries in 7 patients (9%).

Preoperative and postoperative data
Cardiac catheterization was performed 6 to 317 months (mean time, 51 ± 55 months) after the Blalock-Taussig shunt procedure, the mean interval being 86 ± 92 months for classic shunts and 39 ± 23 months for modified shunts. Cineangiograms were reviewed to assess growth of the pulmonary vascular tree, distortion of the pulmonary artery ipsilateral to the shunt, and stenosis of the pulmonary artery at the anastomosis. Both the preoperative and postoperative angiograms were reviewed, and similar measurements were made. Preoperative angiograms were available for 41 shunts (43%) and were used to assess the growth of the pulmonary arteries in the same patients on the postoperative angiograms. The distortion and the anastomotic stenosis of the pulmonary arteries related to the shunts were studied on the postoperative angiograms, available for all 96 shunts. The following measurements were made on the angiograms: the diameter of each pulmonary artery at its origin and immediately before the origin of the first lobar branch and the diameter of the descending aorta at the level of the diaphragm on an anteroposterior cineangiogram. The angiographic frames were traced on paper and measured with a digital caliper (Mitutoyo, Japan). The diameter of each pulmonary artery ipsilateral and contralateral to the subsequent shunt was assessed. All the measurements (in millimeters) were taken during ventricular systole and when possible, from the same angiographic frame. All catheter sizes were recorded, and the magnification factor was determined with reference to the actual size of the catheters on the angiogram. From this, the values were corrected for magnification.

The growth of the pulmonary artery after the Blalock-Taussig shunt procedure was evaluated. The relative size of the pulmonary artery was expressed as the ratio of the diameter of the ipsilateral pulmonary artery (PA) to the diameter of the descending aorta (Ao) (ipsilateral PA to Ao ratio) or the ratio of the sum of the diameters of both pulmonary arteries to the diameter of the descending aorta [7]. These values were compared before and after the shunt operation to assess growth.

Postoperative angiograms, available for all 78 patients, were reviewed to evaluate distortion and stenosis of the pulmonary arteries in relation to the shunts. Any stenosis or distortion at the shunt anastomosis was recorded. The percent stenosis of the pulmonary artery was related to each shunt, and any stenosis greater than 50% was judged to be major. Distortion was defined as tenting or lifting up of the pulmonary artery by the shunt. Angiographic patency was established for every shunt.

At the latest follow-up angiography, the overall patency rate was 90%; 89% of the modified shunts and 92% of the classic shunts were patent. Eighty-two percent of the classic shunts exhibited anastomotic stenosis of the subclavian artery. Overall, 94% of 4-mm grafts, 86% of 5-mm grafts, and 88% of 6-mm grafts were patent at the late study (not significant).

Statistical analysis
All data are shown as the mean ± one standard deviation. The difference between the preoperative ratio and the postoperative ratio was determined, and changes in the ratios were compared by paired Wilcoxon test or t test as appropriate. A p value of less than 0.05 was considered to represent a significant difference.

The respective different sizes of both pulmonary arteries after creation of the shunt, expressed as ipsilateral and contralateral to the shunt, were compared by a paired t test to establish whether or not the growth of the arteries was symmetrical. Patients with bilateral Blalock-Taussig shunts were excluded from this comparison.

Because the growth of the pulmonary arteries may be a function of time, linear regression analysis was performed relating growth of the pulmonary artery and duration of follow-up.

Distortion and major stenosis of the pulmonary artery at the shunt anastomosis were studied using ² test and Mann-Whitney U test as appropriate, and the influence of different factors at the time of implantation such as age, weight, body surface area, sex, hemoglobin level, albumin level, presence of pulmonary atresia, size of the pulmonary artery ipsilateral to the shunt, side of shunt creation in relation to the aortic arch, and type of Blalock-Taussig shunt was assessed.

	Results

Top Footnotes Abstract Introduction Material and methods Results Comment References

 
Increase in size of pulmonary arteries
The preoperative diameter of the branch pulmonary artery on the same side as the subsequent shunt ranged from 3.5 to 15.3 mm (mean size, 7.33 ± 3.05 mm). The largest pulmonary arteries (mean diameter, 8.90 ± 2.90 mm; range, 5.2 to 13.0 mm) were present in patients who had classic shunts and the smallest, in patients who had 4-mm and 5-mm modified Blalock-Taussig shunts. The preoperative diameter of the pulmonary artery ipsilateral to the shunt, expressed as a ratio to the descending aorta (ipsilateral PA to Ao ratio), was smallest in patients who received the 4-mm and 5-mm shunts, whereas the largest preoperative ratio was found in patients who received classic shunts or 6-mm shunts (Table 1). Postoperatively, the increase in the diameter of the pulmonary artery ranged from 55% to 86% (mean increase, 70%) (Table 2). The increase in the absolute diameter of the pulmonary artery was significant in patients with 5-mm and 6-mm modified shunts and classic shunts (p = 0.03, p = 0.001, and p = 0.04, respectively), whereas an increase of borderline significance occurred with 4-mm shunts (p = 0.06) (see Table 1).

Growth of the pulmonary arteries was symmetrical after the shunt was created. Postoperatively, the mean diameter of the pulmonary artery ipsilateral to the shunt was 11.02 ± 4.50 mm, and the diameter of the pulmonary artery contralateral to the shunt increased from a mean preoperative value of 6.69 ± 2.06 mm to 11.25 ± 5.30 mm. The difference between the ipsilateral and contralateral pulmonary artery diameters after the shunt operation was not significant (p = 0.23).

Pulmonary artery stenosis and distortion
Of the 96 shunts studied, 48 (50%) exhibited no distortion or stenosis of the pulmonary arteries (Table 3). Mild stenosis (<50% lumen narrowing) was present in 34 shunts (35%), 24 without and ten with distortion of the pulmonary artery. Thirteen (14%) of the shunts were associated with major stenosis (50%) of the pulmonary artery, six without and seven with distortion of the pulmonary artery. The overall average percent stenosis of the pulmonary artery at the level of the shunt anastomosis was 18% ± 25%. In addition, two complete occlusions of the pulmonary artery at the level of the shunt anastomosis were observed 34 and 82 months after implantation of a 6-mm graft. Major stenosis did not correlate with type of shunt used (classic or modified) (p = 0.34). None of the factors at the time of shunt operation correlated with a significant narrowing of the pulmonary artery at the anastomotic level. Only distortion at the site of the shunt was associated with stenosis (p = 0.0009).

View larger version (95K): [in this window] [in a new window]   Fig 1. Selective angiograms after left modified Blalock-Taussig shunts in 2 patients. (A) Two years after implantation, there is severe narrowing of the left pulmonary artery. (B) Three years after implantation, there is moderate upward tenting without major stenosis of the left pulmonary artery.

	Comment

Top Footnotes Abstract Introduction Material and methods Results Comment References

Conflicting results have been reported after palliation with either a modified or a classic shunt [6, 7, 9–11]. In our study, the diameter of the pulmonary artery ipsilateral to the shunt showed an increase of between 55% and 86% for both classic and modified shunts. However, if the normal growth of the patients is considered, then neither the ipsilateral PA to Ao ratio nor the ratio of the sum of the diameters of both pulmonary arteries to the diameter of the descending aorta increased after the Blalock-Taussig shunt at a faster rate than normal growth. With both of these ratios, it is assumed that the size of the descending aorta is constantly related to the size of the child throughout the study [7]; thus any significant increase in these ratios would reflect the contribution of the Blalock-Taussig shunt to the growth of the pulmonary arterial tree. Significant changes in such ratios after creation of Blalock-Taussig shunts have frequently been reported, but usually these studies have included a small number of patients [4, 6, 7, 9–11]. In our study of a relatively large number of patients, when the preoperative ipsilateral PA to Ao ratio approached 1, it remained unchanged after the shunt procedure. This finding is similar to that reported by others [4, 6]. Guyton and colleagues [6] proposed that when the pulmonary arteries are large prior to a shunt, they grow at the same rate as the descending aorta and should not be expected to grow at a faster rate than the aorta after a shunt. However, when the pulmonary arteries are small before the shunt, they grow at a faster rate than the descending aorta.

In our study, the ipsilateral PA to Ao ratio increased by 58% in the patients with 5-mm shunts. The growth of the pulmonary artery with 4-mm modified shunts was not as good as with the other sizes of shunts. It is possible that smaller pulmonary arteries have a tendency to remain small. Despite an increase in the absolute diameter of the ipsilateral pulmonary artery over time with 4-mm shunts, neither this diameter nor the ipsilateral PA to Ao ratio showed a significant change over time. Preoperatively this group had the smallest pulmonary arteries. A study by Cotrufo and coworkers [4] suggested that Blalock-Taussig shunts do not always produce adequate enlargement of the pulmonary arteries. Similarly, Gale and associates [7] did not find any significant increase in the ratio of the pulmonary annulus to the aorta after a shunt when this ratio was initially small. Though symptomatic improvement and some enlargement of the pulmonary arteries usually occurred, the increase did not exceed the normal growth of the patient.

Growth of the pulmonary arteries after placement of 4-mm shunts is cause for some concern. A classic shunt could be an alternative for neonates with hypoplastic pulmonary arteries, but we do not recommend this option because of the disadvantages of classic shunts: long operative dissection time, phrenic nerve injury, technical difficulties during takedown, and possible arm ischemia [1, 16]. We advise the use of larger-diameter shunts when feasible and reserve the 4-mm grafts for children with hypoplastic pulmonary arteries for whom more complete repair is anticipated within 1 year to 2 years of the modified shunt [16].

In addition, growth of the pulmonary arterial tree correlated poorly with duration of follow-up. A possible factor that contributes to limiting the growth of the pulmonary artery is the development of some shunt narrowing at the level of the anastomoses or excessive intimal growth within the graft, both of which can result in suboptimal flow to the pulmonary arteries. Whereas anastomotic stenoses may be related to the suture material and the surgical technique, the intimal growth within a modified shunt may be related to the time a shunt remains in use. Our study reflects the experience of the 1980s when shunts were in place for a relatively longer period before complete repair was undertaken. More recently, some studies [17, 18] have shown no significant difference in late survival of patients with tetralogy of Fallot between those who had a shunt operation compared with those who had primary repair. These findings tend to support earlier complete surgical repair [19, 20].

Because the Blalock-Taussig shunt is constructed more laterally than centrally on the branch pulmonary artery, symmetric growth of both pulmonary arteries may or may not occur [2, 6, 7]. Growth of the pulmonary arteries occurs as a result of the complex interaction of several factors such as the size of the pulmonary artery, the size of the shunt, and the direction of blood flow from the shunt into the pulmonary artery proximal and distal to the shunt anastomosis. Our study showed that the diameter of the pulmonary artery ipsilateral to the shunt was very similar to that of the contralateral pulmonary artery. Symmetric growth of both pulmonary arteries after Blalock-Taussig shunts has been reported [6, 7, 10]. It has also been suggested that a central shunt may produce better distribution of blood flow and thus enhance the growth of the central pulmonary arteries without resulting in distortion [2]. Subsequent reports have not confirmed this impression [2, 3]. Despite the differential and preferential blood flow to the pulmonary artery on the side of the shunt, Blalock-Taussig shunts are capable of promoting symmetric growth of both pulmonary arteries.

It is recognized that Blalock-Taussig shunts performed in small children with small pulmonary arteries might lead to distortion of the pulmonary arteries [5, 6, 14, 18]. We have observed that younger age at shunt operation tends to result in more distortion of the pulmonary arteries. This further supports the notion of earlier repair of correctable defects. Our study is important in defining the frequency of distortion and stenosis of branch pulmonary arteries in relation to shunts. Prosthetic grafts were more frequently associated with distortion than classic shunts (24% versus 8%). This is of some concern because the patients with modified shunts had a shorter follow-up than those with classic shunts. Thus it may be that if the follow-up were similar, many more patients with modified shunts would be likely to have distortion and possibly stenosis. The frequency of distortion reported previously has varied considerably, ranging from 0% to 36% with a modified shunt [9, 11, 15, 16, 21–23] and from 0% to 75% with a classic shunt [6, 9, 10, 13, 23] (Table 4). Most of these series included a small number of patients who had had repeat cardiac catheterization, and thus the late effects of the shunts were probably underestimated. Our series includes a larger number of patients, thereby reflecting perhaps more accurately the true incidence of distortion and stenosis of the pulmonary arteries produced by shunts.

In conclusion, although Blalock-Taussig shunts undoubtedly result in clinical improvement and are the palliative procedure of choice in some patients with cyanotic heart disease, both modified and classic shunts can produce distortion and stenosis of the pulmonary artery at the site of the shunt anastomosis during medium-term follow-up. Fourteen percent of shunts showed major stenosis of the pulmonary arteries and 19% of shunts showed distortion. The development of distortion was related to younger age at the time of operation, particularly when modified shunts were performed. Although an increase in the size of the pulmonary arteries occurred after both classic and modified Blalock-Taussig shunts, the increase did not exceed the normal rate of growth of the pulmonary arterial tree. Poor growth was noticed after 4-mm shunts. Thus, we recommend the use of larger shunts when feasible and limit the use of 4-mm shunts to children for whom more complete repair is anticipated within 1 year to 2 years of shunt implantation.

	Footnotes

Top Footnotes Abstract Introduction Material and methods Results Comment References

 
Doctor Godart’s current address is Department of Pediatric Cardiology, Lille, France.

	References

Top Footnotes Abstract Introduction Material and methods Results Comment References

 

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