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Ann Thorac Surg 2001;71:905-906
© 2001 The Society of Thoracic Surgeons
a Division of Pediatric Cardiac Surgery, Lucile Packard Children’s Hospital, Stanford University School of Medicine, 300 Pasteur Dr, Stanford, CA 94305-5407, USA
e-mail: michael.black{at}stanford.edu
Successful and staged palliation of children especially with "single" ventricles depends to a large degree on the growth and arborization of the pulmonary vasculature. Perhaps unobtainable, a strategy that would prevent iatrogenic branch arterial stenosis, pulmonary hypertension or prosthetic graft thrombosis would be ideal. Tailoring the type and size of the systemic-to-pulmonary arterial shunt to each neonate’s unique anatomy and habitus remains difficult. Our first attempt at repair is frequently the best, thus a satisfactory neonatal surgical repair should allow a greater proportion of children ultimately achieving a "complete" repair or palliation. In-parallel circulations that require the complete separation of their systemic and venous circulations, ie, Fontan procedure remain the epitome of this philosophy. The placement of nonviable patches or stents within the pulmonary artery in order to correct inherited branch pulmonary arterial kinks, twists, and hypoplastic segments in combination with the low-pressure circuit, currently remains less than ideal [1].
The central shunt allows access to the pulmonary circulation without direct manipulation of the branch pulmonary arteries. The avoidance of the latter should negate or at least reduce the need for future pulmonary arterioplasties (surgical or catheter based intervention) [2]. Frequently the main pulmonary artery in duct dependent lesions, can be accessed and partially occluded with little to no detrimental hemodynamic effects on the neonate. Furthermore, whether stable or not, there should be little change in the perfusion/ventilation ratio with occlusion of the main pulmonary artery in contrast to occlusion of the individual branch pulmonary arteries. Cardiopulmonary bypass (CPB) can be frequently avoided—a real advantage in neonates with precarious coronary circulation, ie, PA/IVS with right ventricular dependent coronary circulation [3].
Obviously, choosing the appropriate diameter and length of shunt remains critical in avoiding a mismatch in the Qp:Qs. Too large of a shunt will increase the ventricular workload, while decreasing the available coronary blood supply. Unlike the modified Blalock-Taussig, a central prosthetic conduit lacks the limiting diameter and governance of the subclavian artery. Conservatism with regard to the diameter of the shunt must be practiced. We have routinely ligated the patent ductus arteriosus upon completion of the central shunt. Not infrequently in neonates with duct dependent physiology is the occurrence of a "ductal sling." When recognized preoperatively a simultaneous repair strategy can be exercised with/without the use of CPB and should not be hampered by the creation of a central shunt.
Doctor Potapov and his colleagues have objectively demonstrated the benefits of the central shunt with further evidence for the inclusion within the armamentarium of successful neonatal surgical procedures. Pulmonary arterial growths without the initial manipulation of the smaller branch pulmonary arteries remain a noteworthy attribute.
References
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