Ann Thorac Surg 2002;74:253-255
© 2002 The Society of Thoracic Surgeons
Case report
Dilatable banding of a Blalock-Taussig shunt
Masahide Chikada, MD*a,
Akihiko Sekiguchi, MDa,
Shinichi Oho, MDa,
Takashi Miyamoto, MDa,
Ryouichi Ishida, MDa,
Hiroo Takayama, MDa,
Akira Ishizawa, MDa
a Division of Cardiovascular Surgery and Cardiology, National Children’s Hospital, Tokyo, Japan
Accepted for publication February 18, 2002.
* Address reprint requests to Dr Chikada, Division of Cardiovascular Surgery and Cardiology, National Children’s Hospital, Tokyo, Japan
e-mail: chikada{at}nch.go.jp
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Abstract
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Dilatable banding has been used in various situations. Sometimes Blalock-Taussig shunt banding is performed to prevent pulmonary overcirculation. Recently several reports have described dilatable pulmonary artery banding. We modified these methods for flow control of a Blalock-Taussig shunt. We report the case of a neonate with truncus arteriosus in which this technique was used.
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Introduction
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Blalock-Taussig shunt banding is sometimes performed to prevent pulmonary overcirculation. If the band is dilatable, the technique has several advantages. We describe the case of a neonate treated with this technique.
A female neonate weighing 2,590 g was referred to us with cyanosis. Echocardiography showed truncus arteriosus (type 2 of Collet and Edwards classification), relatively hypoplastic left ventricle (60% of normal), and ventricular septal defect.
Surgical repair was performed when the patient was 8 days of age. Because the left ventricle was relatively hypoplastic, we performed a palliative operation. Through a median sternotomy, both the superior vena cava and the inferior vena cava were cannulated and moderate hypothermic cardiopulmonary bypass was instituted. Under cardioplegic arrest, the truncal root was transected just proximal and distal to the pulmonary artery origins, and the bilateral origins of the pulmonary artery were removed from the truncal wall. The anterior wall of the removed pulmonary artery was filled with a fresh autologous pericardium. The truncal root was reconstructed by direct anastomosis. A 3.5-mm expanded polytetrafluoroethylene graft was anastomosed between the brachiocephalic artery and the central pulmonary artery. The immediate postoperative course was complicated. Because of high pulmonary blood flow, metabolic acidosis and systemic hypoperfusion occurred, and high systemic oxygen saturation (90%) continued. On the same day, emergency operation was performed in the intensive care unit to reduce the pulmonary blood flow. The brachiocephalic artery, proximal to the anastomosis of the shunt, was banded by a tape made of expanded polytetrafluoroethylene graft. The tape was fixed with 5-0 absorbable polydioxanone suture. After the banding, metabolic acidosis improved, systemic blood pressure increased, and arterial oxygen saturation decreased from 90% to 80%. At 3 months of age, the patient (weighing 3.3 kg) underwent balloon angioplasty because of low systemic oxygen saturation. A 6-mm balloon catheter was used to dilate the band site. The brachiocephalic artery at the band site was dilated from 2.7 mm to 3.3 mm (Fig 1),
and systemic oxygen saturation increased from 73% to 83%.
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Fig 1. (A) Before angioplasty, a brachiocephalic angiogram shows the area of narrowing (between the arrows, 2.6 mm in diameter) at the band site. (B) An angiogram after the balloon dilation shows that the previous band site is dilated to 3.3 mm (between the arrows) in diameter.
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Now the left ventricle volume of the patient is increasing gradually, and biventricular repair is thought to be possible.
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Comment
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The first successful procedure with absorbable polydioxanone pulmonary artery band was reported by Gutierrez de Loma and colleagues [1] in 1991. They treated 5 patients with atrioventricular canal defect or ventricular septal defect in whom pulmonary artery debanding was avoided at subsequent reoperation. Meliones and colleagues [2] reported an experimental study. They used a pulmonary artery band of absorbable material in dogs and demonstrated that the band was balloon dilatable. Taliaferro Warren and colleagues [3] reported a technique of pulmonary artery banding in an animal model using different absorbable sutures. They demonstrated that the band enlarged in a prescribed staged fashion without any further intervention. Recently, Bonnet and colleagues [4] treated 11 infants with aortic coarctation associated with ventricular septal defect using an absorbable pulmonary artery band. They could avoid subsequent open heart operation in 10 of 11 patients. We modified these methods. We allowed a polydioxanone suture to lose its tension resistance for 3 months. After this period, a polydioxanone suture fixing the band was easily cut by the balloon dilatation, thereby loosening the banding.
We performed brachiocephalic artery banding in a life-threatening hemodynamic situation caused by high pulmonary blood flow. Banding a Blalock-Taussig shunt is sometimes necessary. Usually the graft is directly banded to reduce pulmonary blood flow, but in our case the graft had a 3.5-mm diameter. The graft was too small to be banded and not suitable for balloon dilatation. Banding of the brachiocephalic artery is rare [5], but we were able to do it successfully in this case. The best feature of our technique seems to be the option to dilate the banded artery, which can then be "normalized" at the subsequent operation. This technique is thought to be applicable to the Norwood operation or other shunt operations in which pulmonary blood flow is to be reduced.
The potential dangers of this technique are cerebral circulation steal and shunt thrombosis. Another disadvantage is that during the immediate postoperative period the banding is not dilatable. The benefits of this technique, however, outweigh these disadvantages.
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References
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- Gutierrez de Loma J., Ferreiros Mur M., Castilla Moreno M., Garcia Pena R., Gonzalez de Vega N. Reabsorbable banding. Our initial experience. Rev Esp Cardiol 1991;44:677-679.[Medline]
- Meliones J.N., Rocchini A.P., Bove E.L., et al. A balloon-dilatable pulmonary artery band in the dog. Results at one year. J Thorac Cardiovasc Surg 1991;102:790-797.[Abstract]
- Taliaferro Warren E., Heath B.J., Brand W.W. A staged expanding pulmonary artery band. Ann Thorac Surg 1992;54:240-243.[Abstract]
- Bonnet D., Patkai J., Tamister D., et al. A new strategy for the surgical treatment of aortic coarctation associated with ventricular septal defect in infants using an absorbable pulmonary artery band. J Am Coll Cardiol 1999;34:866-870.[Abstract/Free Full Text]
- Schmid F.X., Kampmann C., Kuroczynski W., et al. Adjustable tourniquet to manipulate pulmonary blood flow after Norwood operations. Ann Thorac Surg 1999;68:2306-2309.[Abstract/Free Full Text]
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Abstract
Introduction
