XLI Congresso Nazionale della Società Italiana di Cardiologia Pediatrica, 12-15 Ottobre 2011, Bari
CURRENT RISK FACTORS FOR SYSTEMIC-PULMONARY
SHUNT DYSFUNCTION IN THE NEONATE.
G. Lucchese 1, D. Hila 1, K. Pechlivanidis1, D. Cassater 2, L. Rossetti 2, M.A. Prioli 2, G.
Faggian 1, A. Mazzucco 1, G.B. Luciani 1.
Division of Cardiac Surgery, University of Verona, Verona, Italy. 2 Division of
Cardiology, University of Verona, Verona, Italy.
1
XLI Congresso Nazionale della Società Italiana di Cardiologia Pediatrica, 12-15 Ottobre 2011, Bari
Disclosure
Each author has disclosed any
affiliation, financial agreement, or
other involvement with any company.
Current Risk Factors For Systemic-Pulmonary Shunt Dysfunction In The Neonate.
XLI Congresso Nazionale della Società Italiana di Cardiologia Pediatrica, 12-15 Ottobre 2011, Bari
Background
The Blalock–Taussig shunt (also referred to as
a Blalock-Thomas-Taussig shunt) is
commonly performed in the neonatal period to
increase pulmonary blood flow.
BT shunts may be performed as a single
palliative procedure with planned later more
definitive surgery, or as part of a more
complex surgical intervention (e.g. Norwood
procedure).
Current Risk Factors For Systemic-Pulmonary Shunt Dysfunction In The Neonate.
XLI Congresso Nazionale della Società Italiana di Cardiologia Pediatrica, 12-15 Ottobre 2011, Bari
Background
Mortality*
TGA + DIV
6,9%
MBTS
7,2%
IAA
8,1%
…
…
Truncus Arteriosus
12,1%
(*) STS Report 2010
Current Risk Factors For Systemic-Pulmonary Shunt Dysfunction In The Neonate.
XLI Congresso Nazionale della Società Italiana di Cardiologia Pediatrica, 12-15 Ottobre 2011, Bari
Background
Blalock-Taussig Shunt
One branch of the subclavian artery or
carotid artery is separated and
connected with the pulmonary artery.
The lung receives more blood with low
oxygenation from the body.
Modified Blalock-Taussig Shunt
Obviating the need
to cut off blood
supply and making
it easier to regulate
the blood flow to the
lungs.
Current Risk Factors For Systemic-Pulmonary Shunt Dysfunction In The Neonate.
XLI Congresso Nazionale della Società Italiana di Cardiologia Pediatrica, 12-15 Ottobre 2011, Bari
Background
Modified Blalock-Taussig Shunt
Current Risk Factors For Systemic-Pulmonary Shunt Dysfunction In The Neonate.
XLI Congresso Nazionale della Società Italiana di Cardiologia Pediatrica, 12-15 Ottobre 2011, Bari
Background
Some centers now use
a shunt directly from
the right ventricle to
the pulmonary artery,
a Sano shunt. This is
done to avoid the
reduced diastolic
blood flow in the
coronary circulation
associated with the
Blalock–Taussig
shunt.
Current Risk Factors For Systemic-Pulmonary Shunt Dysfunction In The Neonate.
XLI Congresso Nazionale della Società Italiana di Cardiologia Pediatrica, 12-15 Ottobre 2011, Bari
Background
1.
Current Risk Factors For Systemic-Pulmonary Shunt Dysfunction In The Neonate.
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XLI Congresso Nazionale della Società Italiana di Cardiologia Pediatrica, 12-15 Ottobre 2011, Bari
Objective
Despite numerous reports describing clinical
course of patients undergoing a MBTS,
limited information exists on risk factors for
shunt occlusion.
Aim of the study is to identify clinical and
technical variables associated with shunt
dysfunction in the current surgical era.
Current Risk Factors For Systemic-Pulmonary Shunt Dysfunction In The Neonate.
XLI Congresso Nazionale della Società Italiana di Cardiologia Pediatrica, 12-15 Ottobre 2011, Bari
Patients and Methods
1.
2.
3.
Retrospective study
Period of study from 1997 to 2010
Population:
86 neonates and young infants underwent to MBTS at our
institute
1.
Exclusion criteria were:
1.
2.
3.
2.
3.
Age older than 2 months
Hypoplastic left heart syndrome
Different than systemic-to-pulmonary MBTS
Age ranged from 8 to 62 days (median 16 days)
Weights ranged between 1.7 and 4.5 kilograms (median 2.8
kilograms)
Current Risk Factors For Systemic-Pulmonary Shunt Dysfunction In The Neonate.
XLI Congresso Nazionale della Società Italiana di Cardiologia Pediatrica, 12-15 Ottobre 2011, Bari
Patients and Methods
Diagnoses *
Numbers
%
Tetralogy of Fallot +/- Pulmonary Atresia
31
36%
DORV + Pulmonary Atresia
22
26%
Pulmonary Atresia + Intact Ventricular Septum
11
12%
Tricuspid Atresia
12
14%
Others: Complex Single Ventricle, Heterotaxy
(obstruction of pulmonary blood flow )
10
12%
* Ten (11.6%) patients were operated as emergency.
Current Risk Factors For Systemic-Pulmonary Shunt Dysfunction In The Neonate.
XLI Congresso Nazionale della Società Italiana di Cardiologia Pediatrica, 12-15 Ottobre 2011, Bari
Patients and Methods
Surgical
Techniques *
Off
cardiopulmonary
bypass
On
cardiopulmonary
bypass
Anterior-lateral
thoracotomy
18 (21%)
-
Median sternotomy
-
68 (79%)
* 6 patients required a second MBTS due to inadequate blood flow
through the first (intra-operatively).
Current Risk Factors For Systemic-Pulmonary Shunt Dysfunction In The Neonate.
XLI Congresso Nazionale della Società Italiana di Cardiologia Pediatrica, 12-15 Ottobre 2011, Bari
Patients and Methods
Postoperative anticoagulation scheme
Current Risk Factors For Systemic-Pulmonary Shunt Dysfunction In The Neonate.
XLI Congresso Nazionale della Società Italiana di Cardiologia Pediatrica, 12-15 Ottobre 2011, Bari
Results
SO2
82.5±6.4*
Conduit > 3mm
71.4±8.1
Conduit = 3 mm
(*) p<0,05
Current Risk Factors For Systemic-Pulmonary Shunt Dysfunction In The Neonate.
XLI Congresso Nazionale della Società Italiana di Cardiologia Pediatrica, 12-15 Ottobre 2011, Bari
Results
Diastolic Blood Pressure
24.5±3.9*
Conduit > 3mm
32.4±5.2
Conduit = 3 mm
(*) p<0,05
Current Risk Factors For Systemic-Pulmonary Shunt Dysfunction In The Neonate.
XLI Congresso Nazionale della Società Italiana di Cardiologia Pediatrica, 12-15 Ottobre 2011, Bari
Results
Mean±S
D
ICU Stay
9.1±3.3
*
Hospital Stay
18.6±5.3
Early Mortality
4.6%
(*) 2 Heart failure after ECMO support
(<48 Hours)
2 Sepsis
Current Risk Factors For Systemic-Pulmonary Shunt Dysfunction In The Neonate.
XLI Congresso Nazionale della Società Italiana di Cardiologia Pediatrica, 12-15 Ottobre 2011, Bari
Results
*
(*)
5 MBTS thrombosis
1 sepsis
*
Prevalence of MBTS acute occlusion was 6.0%.
Current Risk Factors For Systemic-Pulmonary Shunt Dysfunction In The Neonate.
XLI Congresso Nazionale della Società Italiana di Cardiologia Pediatrica, 12-15 Ottobre 2011, Bari
Results
Main risk factors for thrombosis. Univariate analysis* :
Weight < 2 kg
P=0,000
Shunt size < 3,5 mm
P=0,000
Emergency procedure
P=0,001
Off CBP procedure
P=0,006
Univentricular heart
P=0,009
(*) SPSS 17.0
Current Risk Factors For Systemic-Pulmonary Shunt Dysfunction In The Neonate.
XLI Congresso Nazionale della Società Italiana di Cardiologia Pediatrica, 12-15 Ottobre 2011, Bari
Results
Main risk factors for thrombosis. Multivariate analysis* :
B
SE
Wald
df
Sig.
Exp(B)
Off-Pump Procedure
3,168
1,121
7,987
1
0,005
23,770
Weight < 2 kg
2,827
1,348
4,398
1
0,036
16,900
Shunt Size < 3,5 mm
1,689
0,858
3,871
1
0,049
5,412
Univentricular Heart
2,978
1,932
4,731
1
0,037
6,956
Emergency Procedure
0,456
0,773
0,348
1
0,555
1,578
(*) SPSS 17.0
Current Risk Factors For Systemic-Pulmonary Shunt Dysfunction In The Neonate.
XLI Congresso Nazionale della Società Italiana di Cardiologia Pediatrica, 12-15 Ottobre 2011, Bari
Conclusions
MBTS still remains a procedure with
elevated early post-operative risk.
Shunt size less than 3,5 mm and
off-pump procedure via thoracotomy are
current risk factors for MBTS occlusion and
inter-stage mortality. Low birth-weight may
be correlated to shunt size.
Current Risk Factors For Systemic-Pulmonary Shunt Dysfunction In The Neonate.
XLI Congresso Nazionale della Società Italiana di Cardiologia Pediatrica, 12-15 Ottobre 2011, Bari
Conclusions
Shunt procedure on cardiopulmonary
bypass, in spite of more profound interference
with coagulation system, is not associated
with higher incidence of thrombotic event of
the conduit.
Current Risk Factors For Systemic-Pulmonary Shunt Dysfunction In The Neonate.
XLI Congresso Nazionale della Società Italiana di Cardiologia Pediatrica, 12-15 Ottobre 2011, Bari
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Current Risk Factors For Systemic-Pulmonary Shunt Dysfunction In The Neonate.