Analysis of Risk Factors for Early Mortality in Surgical Shunt Palliation:Time for a Change?

Objectives:Over the last decade,neonatal repair has been advocated for many congenital heart diseases.However,specific subgroups of complex congenital heart disease still require temporary palliation for which both surgical and endovascular techniques are currently available.We reviewed our institutional experience with shunt palliation with an emphasis on risk factors for early mortality.Methods:This is a single-center retrospective study on 175 patients undergoing surgery for central shunt or modified Blalock-Taussig shunt.All data were extracted from a prospectively collected computerized database.We identified risk factors for early mortality by uni-and multi-variable analysis.All data were censored at the time of death or shunt take-down operation.Results:Mean age and weight at surgery were 24 days(IQR[7–95])and 3.4 kg(IQR[2.9–4.8]),respectively,with 96 neonates(55%).Most patients had a biventricular heart disease(115 patients,66%),and 51 patients(29.1%)had univentricular heart disease.Thoracotomy was performed in 129 patients(74%).Cardiopulmonary bypass was used in 23 patients(13%).The median intensive care and overall length of stay were 4 days(IQR[2–9])and 18 days(IQR[13–29]),respectively.In-hospital mortality was 8.6%(15/175).By multivariable regression analysis,prematurity(HR 5.6[2.1–14.7]),CPB use(HR 6.7[2.2–18.6]),unplanned<30-day reoperation(HR 3.5[1.2–10])or catheterization(HR 4.5[1.2–16.9])were all significant predictors of early mortality.Conclusions:Procedural-related mortality remains high(8.6%)in surgical shunt palliation.For patients with prematurity,low weight at birth,or if the use of cardiopulmonary bypass is contemplated,alternative endovascular techniques of palliation should be considered together with longitudinal follow-up studies.

Analysis of Pulmonary Arteries Growth after Initial Shunt Palliation in Neonates and Infants

Objective:Despite increasing enthusiasm for neonatal repair,patients with ductal-dependent circulation(pulmonary/systemic)or restrictive pulmonary blood flow still require initial palliation.Ductal stenting has emerged as an endovascular approach whereas modified-Blalock-Taussig and central shunt remain surgical references.In this study,we analyzed the relationship between pulmonary artery growth,sites of shunt connection,or antegrade pulmonary blood flow in surgically placed shunts.The need for secondary catheter-based interventions or pulmonary arterioplasty was also investigated.Methods:A retrospective single-center study analyzing 175 patients undergoing surgery for a central or modified-Blalock-Taussig shunt.Outcome growth variables were right pulmonary artery/left pulmonary artery diameters/Z scores,the indexed sum area(right pulmonary artery+left pulmonary artery),and the pulmonary symmetry index.Three imaging modalities were used:angiography,computed tomography,and echocardiography.Results:At baseline,pulmonary arteries were larger in patients with antegrade pulmonary blood flow(Nakata index 137 vs.114,p=0.047)as well as in patients receiving a modified-Blalock-Taussig shunt(Nakata index 138 vs.84,p<0.001).At the time of shunt takedown,both the right pulmonary artery and left pulmonary artery had normalized their diameter.The Nakata index increased from 134 to 233 mm^(2)/m^(2)(p<0.001).The pulmonary artery index remained stable(0.86)over time.During the inter-stage period,shunt-related pulmonary artery stenosis and juxta-ductal stenosis were diagnosed in 16(10%)and 17 patients(11%),respectively.Conclusions:Surgical shunt palliation allows normal pulmonary artery growth.Pulmonary artery stenosis was either shunt-related(10%)or secondary to juxta-ductal stenosis(11%).Close echographic follow-up allows early diagnosis and treatment of juxta-ductal stenosis.