Two Thousand Blalock-Taussig Shunts: A Six-Decade Experience

doi:10.1016/j.athoracsur.2007.06.067

The Annals of Thoracic Surgery

Volume 84, Issue 6, December 2007, Pages 2070-2075

Presented at the Forty-third Annual Meeting of The Society of Thoracic Surgeons, San Diego, CA, Jan 29–31, 2007.

https://doi.org/10.1016/j.athoracsur.2007.06.067 Get rights and content

Background

The Blalock-Taussig shunt (BTS) remains valuable for palliation of congenital heart disease, but its role has evolved. We reviewed our total institutional experience with BTS to examine changes in its use and outcomes.

Methods

A retrospective review was performed of all patients undergoing BTS at our institution from November 1944 to May 2006. Hospital records and autopsy records were evaluated to determine patient demographics, diagnoses, operative data, hospital complications, and long-term outcomes.

Results

During the last 62 years, 2,016 BTS were performed by 28 surgeons on 1,880 patients from 35 countries. Classic BTS were performed in 75% (1,503 of 2,016 BTS). Diagnosis was tetralogy of Fallot in 72% (1,294 of 1,802), although diagnoses were imprecise in the early part of the series. Overall operative mortality was 14% (227 of 1,574). On follow-up, 32% of tetralogy of Fallot patients (411 of 1,294 patients) underwent subsequent total correction at our institution, and an additional 116 patients for whom follow-up was available had total correction of tetralogy of Fallot at other institutions, a combined total correction of tetralogy of Fallot rate of 41%. Of patients with complex congenital heart defects, 26% (106 of 404 patients) had subsequent cavopulmonary connection or atrial or arterial switch procedures. A comparison of the first and second halves of the series revealed several trends: decreasing mean annual number of BTS (66/year versus 9/year, respectively), decreasing operative mortality (16% versus 9%), and increasing proportion of single-ventricle diagnoses (5% versus 34%).

Conclusions

Evolution of the BTS has seen a decrease in overall use, particularly in tetralogy of Fallot, but greater application to single-ventricle cardiac lesions and improved operative survival.

Section snippets

Patient Selection

After obtaining institutional review board approval and waiver of consent, retrospective review was performed of all patients undergoing the BTS procedure at The Johns Hopkins Hospital from November 1944 through May 2006. All patients who underwent some form of systemic to pulmonary shunting procedure were included, regardless of whether this was a part of a larger procedure or set of procedures. The exceptions were patients undergoing central shunts, such as Potts or Waterston shunts. The list

Patients

During the last 62 years, 2,016 BTS were performed by 28 surgeons on 1,880 patients from 35 countries. Data were available on 94.4% (1,774 of 1,880) of patients in this series. Diagnosis was tetralogy of Fallot (TOF) in 72% (1,294 of 1,802), although diagnoses were imprecise in the early part of the series. One hundred sixty patients (9%) had single-ventricle diagnoses and typically had BTS as part of a complex palliative procedure. The percentage of patients undergoing BTS for single-ventricle

Comment

In the early 1970s, Taussig and colleagues [3] first reported long-term results of BTS at our institution. The 12% operative mortality, combined with a 23% late mortality at 15 years, set the standard for surgical palliation of patients with TOF. Although results were inferior for patients with tricuspid atresia [4], truncus arteriosus [5], and transposition of the great vessels [6], the success with these disorders nonetheless demonstrated promise for treatment of many forms of cyanotic heart

References (40)

S. Stewart et al.
Long-term palliation with the classic Blalock-Taussig shunt
J Thorac Cardiovasc Surg
(1988)
J. Lamberti et al.
Systemic-pulmonary shunts in infants and childrenEarly and late results
J Thorac Cardiovasc Surg
(1984)
E. Arciniegas et al.
Classic shunting operations for congenital cyanotic heart defects
J Thorac Cardiovasc Surg
(1982)
V. Smith et al.
The Blalock-Taussig shunt in the newborn infant
J Thorac Cardiovasc Surg
(1991)
P. Chopra et al.
The Blalock-Taussig operation: the procedure of choice in the hypoxic infant with tetralogy of Fallot
Ann Thorac Surg
(1976)
C. Fraser et al.
Tetralogy of Fallot: surgical management individualized to the patient
Ann Thorac Surg
(2001)
S. Bradley et al.
Hemodynamic status after the Norwood procedure: a comparison of right ventricle-to-pulmonary artery connection versus modified Blalock-Taussig shunt
Ann Thorac Surg
(2004)
C. Pizarro et al.
Right ventricle to pulmonary artery conduit reduces interim mortality after stage 1 Norwood for hypoplastic left heart syndrome
Ann Thorac Surg
(2004)
M. Griselli et al.
Influence of surgical strategies on outcome after the Norwood procedure
J Thorac Cardiovasc Surg
(2006)
J. Donahoo et al.
Systemic-pulmonary shunts in neonates and infants using microporous expanded polytetrafluoroethylene: immediate and late results
Ann Thorac Surg
(1980)

Cited by (100)

A Single-Centre Retrospective Review of Modified Blalock-Taussig Shunts: A 22-Year Experience
2023, Heart Lung and Circulation
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.
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.
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.
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.
Blalock-Taussig Shunt versus Ductal Stent in the Palliation of Duct Dependent Pulmonary Circulation; A Systematic Review and Metanalysis
2022, Current Problems in Cardiology
In infants with ductal dependent pulmonary blood flow, Blalock-Taussig (BT) shunt and Patent Ductus Arteriosus (PDA) stent, are two palliative procedures aimed to restore circulation. A systematic review and metanalysis was performed on studies comparing PDA stents and BT shunts, in accordance with PRISMA guidelines. Meta-analysis revealed the following; (1) a reduced risk of mortality [RR = 0.585 [0.399-0.859], (P = 0.006)], (2) a reduced risk of complications [RR = 0.523 [0.318-0.860], (P = 0.011), and (3) a reduced risk of ECMO use [R = 0.267 [0.101-0.706] (P = 0.008)], all in the stent group. Additionally, stent group showed higher post procedure oxygen saturation [SMD = 1.307 [95% CI 1.065-1.550], (P < 0.001)], and Nakata index [SMD = 0.679 95% CI [0.513 to 0.845], (P < 0.001)]. PDA stenting presents a viable alternative to BT shunt procedure with better post procedure stability.
Anterograde blood flow associated with modified Blalock–Taussig shunt does not modify pulmonary artery growth compared with modified Blalock–Taussig shunt alone
2021, Archives of Cardiovascular Diseases
The main difference between extreme tetralogy of Fallot (TOF) and pulmonary atresia with ventricle septal defect (PA/VSD) is anterograde pulmonary blood flow (APBF). It is speculated that the association of modified Blalock–Taussig shunt (mBTS) with APBF favours shunt thrombosis, but promotes better pulmonary artery growth.
To compare pulmonary artery growth after mBTS between TOF and PA/VSD.
From 1995 to 2018, 77 mBTS procedures were performed in infants (aged < 1 year): 45 for TOF; 32 for PA/VSD. Using a 1/1 propensity score-matched analysis, 38 patients were included (19 per group). Delta Nakata was defined as the difference in the Nakata index before biventricular repair and before mBTS.
After matching, the preoperative Nakata index was similar in the two groups (TOF 101 ± 34 vs. PA/VSD 106 ± 35 mm²/m²; P = 0.75). Age and weight were similar (TOF 24 ± 20 days, 3.3 ± 0.6 kg vs. PA/VSD 24 ± 33 days, 3.3 ± 0.9 kg; P = 0.84 and P = 0.77, respectively). There was no difference in rates of in-hospital mortality (TOF 0% vs. PA/VSD 10%; P = 0.13) or mBTS thrombosis (TOF 15% vs. PA/VSD 10%; P = 0.63). The left and right pulmonary artery diameters at time of biventricular repair were similar (TOF 7.5 ± 2.2 and 6.7 ± 2.1 vs. PA/VSD 8 ± 2.7 and 7.1 ± 2.5 mm; P = 0.43 and P = 0.78, respectively), as were delta Nakata (TOF 112 ± 102 vs. PA/VSD 107 ± 66 mm²/m²; P = 0.89), median age for biventricular repair (P = 0.83) and reintervention rates (TOF 10% vs. PA/VSD 15%; P = 0.67).
We found no difference in pulmonary artery growth between APBF with mBTS versus mBTS alone. Thus, we could not show an increase in mBTS thrombosis with APBF.
La principale différence entre les patients avec tétralogie de Fallot (TOF) extrême et l’atrésie pulmonaire avec communication inter ventriculaire (AP/CIV) est le flux sanguin pulmonaire antérograde (FSPA). Il est supposé que l’association du shunt Blalock–Taussig modifié (mBTS) et de l’FSPA favorise la thrombose de ce shunt, mais permet une meilleure croissance des artères pulmonaires.
Cette étude permet de comparer la croissance des artères pulmonaires après mBTS entre TOF et AP/CIV.
De 1995 à 2018, 77 mBTS ont été réalisés chez des enfants (< 1 an), 45 pour TOF et 32 pour AP/CIV. En utilisant une analyse de correspondance du score de propension 1/1, 38 patients ont été inclus (n = 19 dans chaque groupe). Delta Nakata a été défini comme la différence entre l’indice de Nakata avant la réparation biventriculaire et avant le mBTS.
Après appariement, l’indice de Nakata préopératoire était similaire dans les deux groupes (TOF 101 ± 35 vs AP/CIV 106 ± 34 mm²/m² ; p = 0,75). L’âge et le poids étaient similaires (TOF 24 ± 20 jours, 3,3 ± 0,6 kg vs AP/CIV 24 ± 33 jours, 3,3 ± 0,9 kg ; p = 0,84 et p = 0,77, respectivement). Il n’y avait pas de différence pour la mortalité hospitalière (TOF 0 % vs AP/CIV 10 % ; p = 0,13) et pour la thrombose de shunt (TOF 15 % vs AP/CIV 10 % ; p = 0,63). Les diamètres des artères pulmonaires gauche et droit au moment de la réparation biventriculaire étaient similaires (TOF 7,5 ± 2,2 et 6,7 ± 2,1 vs AP/CIV 8 ± 2,7 et 7,1 ± 2,5 mm ; p = 0,43 et p = 0,78, respectivement), ainsi que delta Nakata (TOF 112 ± 102 vs AP/CIV 107 ± 66 mm²/m² ; p = 0,89). L’âge médian de la réparation biventriculaire était similaire (p = 0,83). Les ratios de réinterventions étaient similaires (TOF 10 % vs AP/CIV 15 % ; p = 0,67).
Nous n’avons pas pu montrer de différence pour la croissance des artères pulmonaires entre le groupe voie antérograde avec le mBTS par rapport au mBTS seul. Ainsi, nous n’avons pas pu montrer une augmentation de la thrombose de mBTS avec l’FSPA.
Haemodynamic and clinical variables after surgical systemic to pulmonary artery shunt placement versus arterial ductal stenting
2023, Cardiology in the Young
Surgical versus transcatheter palliation for insufficient pulmonary blood supply in infants with cyanotic CHD
2022, Cardiology in the Young
Are early palliative procedures providing an adequate long-term benefit in young cyanotic infants from developing countries, despite advances in surgery and interventions?
2021, Cardiology in the Young

View all citing articles on Scopus

View full text

Original articleCardiovascularTwo Thousand Blalock-Taussig Shunts: A Six-Decade Experience

Background

Methods

Results

Conclusions

Section snippets

Patient Selection

Patients

Comment

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

Ann Thorac Surg

Ann Thorac Surg

Ann Thorac Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

Ann Thorac Surg

The surgical treatment of malformations of the heart in which there is pulmonary stenosis or pulmonary atresia

JAMA

Has the time come to rename the Blalock-Taussig shunt?

Pediatr Crit Care Med

Long-time observations on the Blalock-Taussig operationI. Results of first operation

Johns Hopkins Med J

Long-time observations on the Blalock-Taussig operationIV. Tricuspid atresia

Johns Hopkins Med J

Long-time observations on the Blalock-Taussig operationVI. Truncus arteriosus IV

Johns Hopkins Med J

Long-time observations on the Blalock-Taussig operationVII. Transposition of the great vessels and pulmonary stenosis

Johns Hopkins Med J

Hypoplastic left heart syndromeOutcome after initial reconstruction and before modified Fontan procedure

Circulation

Original article
Cardiovascular
Two Thousand Blalock-Taussig Shunts: A Six-Decade Experience