Blalock-Taussig shunt

	Blalock-Taussig shunt Microchapters
Overview
Historical Perspective
Classification
Goals of BT shunt
Indications
Risk Factors
Preparation for BT Shunt
Complications
Prognosis
Alternative Shunts

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

The Blalock-Taussig shunt is a palliative surgical procedure done for cyanotic heart defects. This procedure is used to deviate blood flow to lungs from the systemic circulation to relieve cyanosis while a definitive corrective surgery can be performed at a later time. Connection between subclavian artery and pulmonary artery is usually made. Usually, two types of shunts are used i.e classic or original Blalock-Taussig shunt and modified Blalock Taussig shunt. The classic/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. This type of BT shunt has superior prognostic value over the classical shunt leading to a greater rate of shunt patency in 3-5 years as compared to the classic or original BT Shunt.

Historical Perspective

Classic or Original Shunt

The classic or original BT shunt procedure was named after a surgeon in Baltimore, Alfred Blalock (1899–1964), and a cardiologist in Baltimore/Boston, Helen B. Taussig (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 a longer lifetime than those without PDA.
In 1943, Dr. Taussig approached Blalock and Thomas in their Hopkins laboratory to work on this shunt as it was hypothesized that a shunt mimicking PDA can relieve the cyanosis and improve oxygenation in congential cyanotic diseases.^[1]

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

Modified Blalock-Taussig Shunt

In 1962, a modified method of inserting a shunt was developed by Klinner using teflon as a prosthetic graft material between the subclavian artery and the pulmonary artery in order to prevent scarring of the subclavian artery.^[2]^[3]^[4]

Classification

Classic/Original Blalock-Taussig Shunt

For classic Blalock-Taussig shunt, an end-to-end anastomosis opposite to the aortic arch is performed between the subclavian and pulmonary arteries to minimize the kinking of subclavian artery as it crosses aortic prominence.^[4]

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

In 1962, it was first described and performed by Klinner et al.
It is the most commonly used procedure nowadays and holds a superb prognosis over the 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.^[4]

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

Goals of BT shunt

The ultimate endpoint goals of BT shunt are as follows:
- 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

Following is a list of indications for Blalock-Taussig shunt:
- Tricuspid atresia
- Tetralogy of Fallot
- Ebstein's Anomaly
- Hypoplastic Left Heart syndrome
- Pulmonary atresia
- Inadequate pulmonary arteries

Risk Factors

Following multiple risk factors have been identified to be associated with high morbidity and mortality in neonates:^[5]^[6]
- Sternal approach for MBTS construction
- Univentricular heart
- Complicated surgery (CABG)
- Weight <3 kg
- Pre-operative ventilation support
- Pre-operative acidosis and shock
- Use of Innominate artery-PA shunt
- Diagnosis of Ebstein's Anomaly

Preparation for BT Shunt

To perform a BT shunt following pre-operative preparation is done:
- Preoperative psychological counseling of the patient
- Preoperative fasting
- Preoperative medications
Anesthesia induction is based on the following patient and surgery-related factors:

Patient-Related Factors

Diagnosis of a relative congenital cardiac anomaly
Age of the patient
Weight <3 kg leads to a high mortality and morbidity
Premature infants
Any non-cardiac coexisting congenital anomaly such as:
- Tracheoesophageal fistula
- Cleft lip and palate
- Renal anomalies
- Skeletal defects.
Atlantoaxial instability or subluxation in Down syndrome should be considered while managing the airway.
Fatigue, and/or dyspnea on feeding or any other factor showing exercise intolerance.
Use of medications that can lead to an increase in operative mortality such as:
Congenital conditions such as subglottic stenosis that can lead to difficulty in gaining access for intubation.
Optimal right ventricular function

Factors Related to Surgical Procedure

Complex lesions lead to high overall and in-hospital mortality.
Duration of the surgery
Cardiovascular anomalies that can lead to complexity of the procedure such as aortic arch anomaly or presence of aberrant subclavian artery.
Injury to the recurrent laryngeal nerve or phrenic nerve during the procedure.
Nature and approach of the cardiac surgery e.g., cardiopulmonary bypass, sternotomy or thoracotomy.

Approach

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

Complications

The immediate post-operative complications include:^[3]
- Development of chylothorax, chylopericardium and chylous ascites
- Phrenic nerve resection leading to diaphragmatic paralysis
- Anemia
- Congestive Heart failure resulting from excessive blood flow
- Modified PTFE grafts can result in formation of seroma or shunt occlusion due to hyperplasia of neo-intima
- Stenosis of innominate artery
- Sunt Infection resulting in sepsis

Unilateral pulmonary edema, Blalock-Taussig shunt in pulmonary atresia with a 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 follows:
- 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 the 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 a 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 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:

For mild to moderate symptoms fluid resuscitation and diuretics is given. Permissive hypercapnia and lowering of FiO2 is done.
For severe symptoms systemic vascular resistance and pulmonary vascular resistance is adjusted.
Refractory to medical management cases are usually treated with a surgical approach that involves pulmonary artery band or clamping.

Prognosis

Modified Blalock-Taussig Shunt has a superior prognostic value over classic Blalock-Taussig Shunts. Following prognostic factors are compared between the two procedures in multiple studies:^[7]^[8]^[9]^[10]^[11]^[12]
- The increase in saturation of oxygen is greater in the modified shunt as compared to the classic shunt.
- Modified shunt has an 88.8% patency rate in 3-5 years. Whereas for the classic shunt, the patency rate is 90% in the first year, 62% in two years, and 78.0% in 3 years.
- The risk of early shunt failure is 20.8% in modified and 51.7% in the 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. ^[13]
Internal mammary artery is used for this purpose and to create a systemic to pulmonary conduit after there has been a 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.^[14]


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 ^[15]

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 the 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

↑ https://www.upenn.edu/pennpress/book/1904.html
↑ 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.
↑ ^3.0 ^3.1 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.
↑ ^4.0 ^4.1 ^4.2 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.
↑ 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).
↑ 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).
↑ 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.
↑ 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.
↑ 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.
↑ 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.
↑ 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.
↑ 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.
↑ 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.
↑ 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.
↑ 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.

[1] ttps://www.upenn.edu/pennpress/book/1904.html

[pmid144570412-2] 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.

[pmid19040408-3] 3.0 ^3.1 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.

[pmid28701598-4] 4.0 ^4.1 ^4.2 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.

[pmidhttps://doi.org/10.1016/j.jamcollsurg.2012.12.027-5] 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.jamcollsurg.2012.12.027 Check |pmid= value (help).

[pmidhttps://doi.org/10.1016/j.athoracsur.2011.02.030-6] 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).

[pmid9855103-7] 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.

[pmid16337132-8] 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.

[pmid3968910-9] 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.

[pmid10707705-10] 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.

[pmid2441893-11] 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.

[pmid3675059-12] 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.

[Eghtesady_2015_pp._293–305-13] 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.

[Yuan_Jing_2009_pp._549–557-14] 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.

[TRUCCONE_BOWMAN_MALM_GERSONY_1974_pp._508–511-15] 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.

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