Blalock-Taussig shunt: Difference between revisions

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==Overview==
==Overview==
The '''Blalock-Taussig shunt''' is a [[surgical procedure]] that are done as [[Palliative treatment|palliative]] procedures for [[cyanotic heart defect]]s . This procedure is used to deviate blood flow to lungs from systemic circulation to relieve [[cyanosis]] while a definitive [[corrective surgery]] can be performed at later time. Connection between [[subclavian artery]] and [[pulmonary artery]] is usually made . There are usually two types of [[Shunt (medical)|shunts]] that are used i.e classic or original Blalock-Taussig shunt and modified Blalock Taussig shunt. The classic or original BT shunt  has been modified into modified Blalock-Taussig Shunt (mBTS). In this modified procedure a [[graft]] from [[innominate artery]] or [[subclavian artery]] is placed to the corresponding [[pulmonary artery]]. <ref name="pmid28701598" />This type of BT shunt has superior [[Prognosis|prognostic]] value over classical shunt leading to greater rate of shunt patency at 3-5 years as compared to classic or original BT Shunt.<ref name="pmid19040408" />   
 
* The '''Blalock-Taussig shunt''' is a [[surgical procedure]] that are done as [[Palliative treatment|palliative]] procedures for [[cyanotic heart defect]]s .  
* This procedure is used to deviate blood flow to lungs from systemic circulation to relieve [[cyanosis]] while a definitive [[corrective surgery]] can be performed at later time. Connection between [[subclavian artery]] and [[pulmonary artery]] is usually made  
* There are usually two types of [[Shunt (medical)|shunts]] that are used i.e classic or original Blalock-Taussig shunt and modified Blalock Taussig shunt.  
* The classic or original BT shunt  has been modified into modified Blalock-Taussig Shunt (mBTS). In this modified procedure a [[graft]] from [[innominate artery]] or [[subclavian artery]] is placed to the corresponding [[pulmonary artery]]. <ref name="pmid28701598" />
* This type of BT shunt has superior [[Prognosis|prognostic]] value over classical shunt leading to greater rate of shunt patency at 3-5 years as compared to classic or original BT Shunt.<ref name="pmid19040408" />   


== Historical Perspective ==
== Historical Perspective ==


=== Classic or Original Shunt ===
=== Classic or Original Shunt ===
The classic or original BT shunt procedure was named for [[Alfred Blalock]], surgeon, Baltimore, (1899–1964) and [[Helen B. Taussig]], cardiologist, Baltimore/Boston, (1898–1986) who, along with Blalock's African American laboratory technician [[Vivien Thomas]] (1910–1985), developed and described the procedure. Taussig noticed that the children with cyanosis along with [[congenital heart disease]] accompanied by [[patent ductus arteriosus]] have longer life time than those without PDA. Dr. Taussig approached Blalock and Thomas in their Hopkins laboratory in 1943 to work upon in this shunt as it was hypothesized that a shunt mimicking [[PDA]] can relieve the cyanosis and improve [[oxygenation]] in [[congential cyanotic diseases]]. {{cite book | last = Thomas | first = Vivien | title = Partners of the heart : Vivien Thomas and his work with Alfred Blalock : an autobiography | publisher = University of Pennsylvania Press | location = Philadelphia | year = 1985 | isbn = 0812216342 }}
 
* The classic or original BT shunt procedure was named for [[Alfred Blalock]], surgeon, Baltimore, (1899–1964) and [[Helen B. Taussig]], cardiologist, Baltimore/Boston, (1898–1986) who, along with Blalock's African American laboratory technician [[Vivien Thomas]] (1910–1985), developed and described the procedure.  
* Taussig noticed that the children with cyanosis along with [[congenital heart disease]] accompanied by [[patent ductus arteriosus]] have longer life time than those without PDA. Dr. Taussig approached Blalock and Thomas in their Hopkins laboratory in 1943 to work upon in this shunt as it was hypothesized that a shunt mimicking [[PDA]] can relieve the cyanosis and improve [[oxygenation]] in [[congential cyanotic diseases]]. {{cite book | last = Thomas | first = Vivien | title = Partners of the heart : Vivien Thomas and his work with Alfred Blalock : an autobiography | publisher = University of Pennsylvania Press | location = Philadelphia | year = 1985 | isbn = 0812216342 }}


[[File:Original-blalock-taussig-shunt-creative-commons.png|thumb|200px|none|Original Blalock-Taussig shunt diagram. [https://radiopaedia.org/cases/74774 Source: Dr Laurent Bilodeau.]]]
[[File:Original-blalock-taussig-shunt-creative-commons.png|thumb|200px|none|Original Blalock-Taussig shunt diagram. [https://radiopaedia.org/cases/74774 Source: Dr Laurent Bilodeau.]]]

Revision as of 07:22, 24 June 2020

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Usman Ali Akbar, M.B.B.S.[2]

Synonyms and keywords: Blalock Taussig Procedure,Procedure, Blalock-Taussig,Subclavian Pulmonary Artery Shunt,Blue Baby Operations,Modified Blalock-Taussig Procedure

Overview

Historical Perspective

Classic or Original Shunt

  • The classic or original BT shunt procedure was named for Alfred Blalock, surgeon, Baltimore, (1899–1964) and Helen B. Taussig, cardiologist, Baltimore/Boston, (1898–1986) who, along with Blalock's African American laboratory technician Vivien Thomas (1910–1985), developed and described the procedure.
  • Taussig noticed that the children with cyanosis along with congenital heart disease accompanied by patent ductus arteriosus have longer life time than those without PDA. Dr. Taussig approached Blalock and Thomas in their Hopkins laboratory in 1943 to work upon in this shunt as it was hypothesized that a shunt mimicking PDA can relieve the cyanosis and improve oxygenation in congential cyanotic diseases. Thomas, Vivien (1985). Partners of the heart : Vivien Thomas and his work with Alfred Blalock : an autobiography. Philadelphia: University of Pennsylvania Press. ISBN 0812216342.
Original Blalock-Taussig shunt diagram. Source: Dr Laurent Bilodeau.


Modified Blalock-Taussig Shunt

A modified method of inserting a shunt was developed in 1962 by Klinner using teflon as prosthetic graft material between the subclavian artery and the pulmonary artery is used to prevent scarring of the subclavian artery. [3]

Modified Blalock-Taussig shunt diagram. Source: Dr Laurent Bilodeau.


Goals of BT shunt

The ultimate endpoint goals of BT shunt is

  • To stabilize the preload hence preventing hemodilution.
  • To maintain Systemic Vascular Resistance ( afterload ) hence adequate diastolic pressure to maintain coronary perfusion
  • Increase the blood flow to the pulmonary vasculature in a supervised manner

Indications

Risk Factors

Multiple risk factors have been identified which leads to high morbidity and mortality in neonates. [4] [5]

  • Sternal approach for MBTS construction
  • Univentricular heart
  • Complicated surgery- (CABG)
  • Weight <3 kg
  • Pre-op ventilation support
  • Pre-op acidosis and shock
  • Use of Innominate artery-PA shunt
  • Diagnosis of Ebstein's Anomaly

Classification

Classic/Original Blalock-Taussig Shunt

Classic/Original Blalock-Taussig Shunt
Advantages Disadvantages
The relative diameter of subclavian artery prevents excessive blood flow to lungs Thrombosis of shunt due to less diameter
Easily Reversible Risk of Dissection
Increased rate of anastomosis growth Subclavian artery is lost during the procedure

Modified Blalock Taussig Shunt

It is the most commonly used procedure now a days. First described and performed by Klinner et. al in 1962, this procedure hold superb prognosis over classic one. An Interposition PTFE or Gore-Tex graft is placed between the subclavian artery and the pulmonary artery. Hence no scarring of subclavian artery results.[1]

Modified Blalock Taussig Shunt
Advantages Disadvantages
It can be done on the same side of the arch Thrombosis
More patency than Classic BT shunt i.e >90 % at 2 years Pseudoaneurysm
Pulmonary artery is less distorted Chylothorax, Chylopericardium, chylous ascites


Preparation for BT Shunt

To perform a BT shunt following pre-op preparation is done

Anesthesia induction will be based on the following patient and surgical factors

Patient Related Factors

Factors Related to Surgical Procedure

Approach

  • For right sided modified Blalock-Taussig shunt (mBTS), left lateral position is used and for left sided mBTS right lateral position is used. The approach used is usually thoracotomy.
  • For central shunts sternotomy is performed.

Complications

The immediate post-operative complications include [2]

Unilateral pulmonary edema, blalock-taussig shunt in pulmonary atresia with ventricular septal defect. Source: Dr. Charlie Chia-Tsong.

Management of Complications

Shunt failure

It is the most immediate risk during the post-operative period. It can lead to drop in oxygen saturation secondary due to shunt thrombosis or kinking. Shunt failure is a surgical emergency and should be managed as following :

  • Anticoagulation should be started. Heparin should be instituted promptly. It should be again administered if there is less risk of bleeding usually after 4 hours post-op ( when the drainage of chest shows <3ml/kg/h and aPTT is <60s. Heparin induced thrombocytopenia can occur and should be managed accordingly.
  • Patient is put on aspirin which is usually started at 3-5 mg/kg (max. dose 75mg ) OD.
  • Heparin should be continued until there is second dose of aspirin.

Blockage of BT shunt

Blockage or shunt thrombosis is another surgical emergency. It's incidence has reported around 12 %. Any recent onset murmur or significant drop in oxygen saturation must be investigated . Operative management is usually required and the shunt is usually repaired or replaced if necessary.

High pulmonary blood flow

The appropriate size of BT shunt is very important to prevent the long term complications regarding to high pulmonary blood flow or high oxygen saturation. Chest X Ray usually shows edematous lungs with low mixed venous saturation , rising lactate levels or signs of right heart failure, systemic diastolic pressure may be low , persistent metabolic acidosis leading to "pink patient" and pulmonary hemorrhage.

Causes
  • High FiO2
  • PDA still open leading to excessive blood delivery to lungs
  • Large shunt diameter
Treatment

Following treatment is instituted.

Prognosis

Modified Blalock-Taussig Shunt has superior prognostic value over classic Blalock-Taussig Shunts. Following prognostic factors are compared between the two procedures in multiple studies. [6] [7] [8] [9] [10] [11]

  • Rise in saturation of oxygen is greater in modified than in classic shunt
  • Shunt patency is 88.8 % in modified for 3-5 years versus 90 % in first year, 62 % in two years and 78.0 % in 3 years for classic shunt.
  • The risk of early shunt faliure is 20.8 % in modified and 51.7% in classic shunt.
  • Post-shunt increase in pulmonary arterial index (mm2/m2) is 158 +/- 21 versus 117 +/- 52 in classic Blalock-Taussig shunt.
Blalock-taussig shunt annotated image, Source: Dr. Vincent Tatco.

Alternative Shunts

Central Shunt

Central shunt is made by making a anastomosis between ascending aorta and main pulmonary artery. A short PTFE conduit for this purpose is used. It is also known as Mee's shunt. [12] Internal mammary artery is used for this purpose and to create a systemic to pulmonary conduit after there has been failure of previously used BT shunt. It leads to adaptation of growth and flow and reduces the risk for graft infection.

Advantages Disadvantages
Can be done in small children with small vessels Can not be performed without in patients without patent ductus arteriosus
Distortion of pulmonary vessels is avoided Entry into pericardium
Equal blood flow is provided to both lungs
Low chance of occlusion rate
Subclavian steal syndrome is usually avoided

Potts shunt

It can be used as an alternative to Classic BT shunt. To avoid the consequences of right heart failure, it has been used as an alternative to offload the right ventricle. This improves the cardiac output but the oxygen saturation is lowered and there is decreased oxygen delivery to lower extremities. Pott's shunt includes a connection that is made between descending aorta and left pulmonary artery. [13]

Advantages Disadvantages
Subclavian artery is used hence large diameter so surgery can be easily performed Increased incidence of pulmonary hypertension
Lower chance of occlusion than CBTS and mBTS Increased blood flow to one lung while there is kinking of pulmonary artery
Increased risk of congestive heart failure [14]

Waterston shunt

It is made by connecting the ascending aorta and right pulmonary artery. It has not been clinically performed now due to increased risk of congestive heart failure , pulmonary hypertension and kinking of pulmonary artery

Cooley Shunt

It is an intrapericardial anastomosis between ascending aorta and the right pulmonary artery. Right anterolateral thoracotomy approach is used.

Advantages Disadvantages
Use of right anterolateral incision for all approaches - Mediastinal dissection is avoided Improper size of shunt can lead to right heart failure and pulmonary congestion
Total repair can be done after this shunt in future Risk of intracardiac adhesions
Complexity of the procedure


References

  1. 1.0 1.1 1.2 Kiran U, Aggarwal S, Choudhary A, Uma B, Kapoor PM (2017). "The blalock and taussig shunt revisited". Ann Card Anaesth. 20 (3): 323–330. doi:10.4103/aca.ACA_80_17. PMC 5535574. PMID 28701598.
  2. 2.0 2.1 Yuan SM, Shinfeld A, Raanani E (2009). "The Blalock-Taussig shunt". J Card Surg. 24 (2): 101–8. doi:10.1111/j.1540-8191.2008.00758.x. PMID 19040408.
  3. KLINNER W, PASINI M, SCHAUDIG A (1962). "[Anastomosis between systemic and pulmonary arteries with the aid of plastic prostheses in cyanotic heart diseases]". Thoraxchirurgie. 10: 68–75. doi:10.1055/s-0028-1096482. PMID 14457041.
  4. Schmoldt A, Benthe HF, Haberland G (1975). "Digitoxin metabolism by rat liver microsomes". Biochem Pharmacol. 24 (17): 1639–41. PMID https://doi.org/10.1016/j.jamcollsurg.2012.12.027 Check |pmid= value (help).
  5. Schmoldt A, Benthe HF, Haberland G (1975). "Digitoxin metabolism by rat liver microsomes". Biochem Pharmacol. 24 (17): 1639–41. PMID https://doi.org/10.1016/j.athoracsur.2011.02.030 Check |pmid= value (help).
  6. Al Jubair KA, Al Fagih MR, Al Jarallah AS, Al Yousef S, Ali Khan MA, Ashmeg A; et al. (1998). "Results of 546 Blalock-Taussig shunts performed in 478 patients". Cardiol Young. 8 (4): 486–90. doi:10.1017/s1047951100007150. PMID 9855103.
  7. Kim HK, Kim WH, Kim SC, Lim C, Lee CH, Kim SJ (2006). "Surgical strategy for pulmonary coarctation in the univentricular heart". Eur J Cardiothorac Surg. 29 (1): 100–4. doi:10.1016/j.ejcts.2005.10.032. PMID 16337132.
  8. Karpawich PP, Bush CP, Antillon JR, Amato JJ, Marbey ML, Agarwal KC (1985). "Modified Blalock-Taussig shunt in infants and young children. Clinical and catheterization assessment". J Thorac Cardiovasc Surg. 89 (2): 275–9. PMID 3968910.
  9. Kulkarni H, Rajani R, Dalvi B, Gupta KG, Vora A, Kelkar P (1995). "Effect of Blalock Taussig shunt on clinical parameters, left ventricular function and pulmonary arteries". J Postgrad Med. 41 (2): 34–6. PMID 10707705.
  10. Bove EL, Kohman L, Sereika S, Byrum CJ, Kavey RE, Blackman MS; et al. (1987). "The modified Blalock-Taussig shunt: analysis of adequacy and duration of palliation". Circulation. 76 (3 Pt 2): III19–23. PMID 2441893.
  11. Ullom RL, Sade RM, Crawford FA, Ross BA, Spinale F (1987). "The Blalock-Taussig shunt in infants: standard versus modified". Ann Thorac Surg. 44 (5): 539–43. doi:10.1016/s0003-4975(10)62119-4. PMID 3675059.
  12. Eghtesady, Pirooz (2015). "Potts Shunt for Children With Severe Pulmonary Hypertension". Operative Techniques in Thoracic and Cardiovascular Surgery. Elsevier BV. 20 (3): 293–305. doi:10.1053/j.optechstcvs.2016.02.003. ISSN 1522-2942.
  13. Yuan, Shi-Min; Jing, Hua (2009). "Palliative procedures for congenital heart defects". Archives of Cardiovascular Diseases. Elsevier BV. 102 (6–7): 549–557. doi:10.1016/j.acvd.2009.04.011. ISSN 1875-2136.
  14. TRUCCONE, NESTOR J.; BOWMAN, FREDERICK O.; MALM, JAMES R.; GERSONY, WELTON M. (1974). "Systemic-Pulmonary Arterial Shunts in the First Year of Life". Circulation. Ovid Technologies (Wolters Kluwer Health). 49 (3): 508–511. doi:10.1161/01.cir.49.3.508. ISSN 0009-7322.