Development of Pulmonary Arteries after a Central End-to-Side Shunt in Patients with Pulmonary Atresia, Ventricular Septal Defect, and Diminutive Pulmonary Arteries

Abstract

Aim To evaluate the development of pulmonary arteries (PAs) in patients with pulmonary atresia, ventricular septal defect, and diminutive PAs by using a central end-to-side shunt.

Methods A total of 103 consecutive patients (71 male and 32 female) with pulmonary atresia, ventricular septal defect, and diminutive PAs received a central end-to-side shunt between PA and aorta from May 2004 to December 2010. The age and weight ranged between 2 to 86 months and 2.5 to 21.5 kg, respectively. Overall 79 patients with main PA diameters less than 4 mm received a central end-to-side shunt between PA and aorta, and 24 patients with main PAs absence received a modified central shunt between PA branches and aorta.

Results There were no deaths during operation and follow-up. Compared with preoperative measures, total PA index increased from mean value 68.8 ± 11.4 mm²/m² to 129.1 ± 24.9 mm²/m² (p < 0.001). The increased PA index change at the time of 6 months or final repair after shunt completion was 87.7 ± 27.4% (27–150%). By multivariate regression analysis, age at shunt, shunt procedure, and number of major aortopulmonary collateral arteries were correlated with increasing PA index change.

Conclusion The central end-to-side shunt promoted sufficient growth of the diminutive central PAs, especially in infant patients. Due to the risk of a distortion of pulmonary branches, the authors interposed a modified procedure for patients with main PAs absence by anastomosis of left PA and right PA directly in an end-to-side fashion to the both lateral wall of ascending aorta. It is technically easy to perform, warrants low risk of shunt thrombosis, and flow restriction in the early postoperative period.

Keywords

palliative shunt - pulmonary atresia - diminutive pulmonary artery - development

• References

• 1 d'Udekem Y, Alphonso N, Nørgaard MA , et al. Pulmonary atresia with ventricular septal defects and major aortopulmonary collateral arteries: unifocalization brings no long-term benefits. J Thorac Cardiovasc Surg 2005; 130 (6) 1496-1502
• 2 Griselli M, McGuirk SP, Winlaw DS , et al. The influence of pulmonary artery morphology on the results of operations for major aortopulmonary collateral arteries and complex congenital heart defects. J Thorac Cardiovasc Surg 2004; 127 (1) 251-258
• 3 Duncan BW, Mee RB, Prieto LR , et al. Staged repair of tetralogy of Fallot with pulmonary atresia and major aortopulmonary collateral arteries. J Thorac Cardiovasc Surg 2003; 126 (3) 694-702
• 4 Batra AS, Starnes VA, Wells WJ. Does the site of insertion of a systemic-pulmonary shunt influence growth of the pulmonary arteries?. Ann Thorac Surg 2005; 79 (2) 636-640
• 5 Watterson KG, Wilkinson JL, Karl TR, Mee RB. Very small pulmonary arteries: central end-to-side shunt. Ann Thorac Surg 1991; 52 (5) 1132-1137
• 6 Dragulescu A, Kammache I, Fouilloux V , et al. Long-term results of pulmonary artery rehabilitation in patients with pulmonary atresia, ventricular septal defect, pulmonary artery hypoplasia, and major aortopulmonary collaterals. J Thorac Cardiovasc Surg 2011; 142 (6) 1374-1380
• 7 Ishibashi N, Shin'oka T, Ishiyama M, Sakamoto T, Kurosawa H. Clinical results of staged repair with complete unifocalization for pulmonary atresia with ventricular septal defect and major aortopulmonary collateral arteries. Eur J Cardiothorac Surg 2007; 32 (2) 202-208
• 8 Potapov EV, Alexi-Meskishvili VV, Dähnert I, Ivanitskaia EA, Lange PE, Hetzer R. Development of pulmonary arteries after central aortopulmonary shunt in newborns. Ann Thorac Surg 2001; 71 (3) 899-905 , discussion 905–906
• 9 Mumtaz MA, Rosenthal G, Qureshi A , et al. Melbourne shunt promotes growth of diminutive central pulmonary arteries in patients with pulmonary atresia, ventricular septal defect, and systemic-to-pulmonary collateral arteries. Ann Thorac Surg 2008; 85 (6) 2079-2083 , discussion 2083–2084
• 10 Ugurlucan M, Sayin OA, Nisli K, Aydogan U, Dayioglu E, Tireli E. Modified central aortopulmonary shunt with end-to-end anastomosis of the shunt to the pulmonary trunk: Early results of a novel shunt procedure for first-stage palliation of infants with pulmonary atresia and hypoplastic pulmonary arteries. Thorac Cardiovasc Surg 2009; 57 (2) 85-90
• 11 Song SW, Park HK, Park YH, Cho BK. Pulmonary atresia with ventricular septal defects and major aortopulmonary collateral arteries. Circ J 2009; 73 (3) 516-522
• 12 Gedicke M, Morgan G, Parry A, Martin R, Tulloh R. Risk factors for acute shunt blockage in children after modified Blalock-Taussig shunt operations. Heart Vessels 2010; 25 (5) 405-409
• 13 Wells WJ, Yu RJ, Batra AS, Monforte H, Sintek C, Starnes VA. Obstruction in modified Blalock shunts: a quantitative analysis with clinical correlation. Ann Thorac Surg 2005; 79 (6) 2072-2076
• 14 O'Connor MJ, Ravishankar C, Ballweg JA , et al. Early systemic-to-pulmonary artery shunt intervention in neonates with congenital heart disease. J Thorac Cardiovasc Surg 2011; 142 (1) 106-112
• 15 Ahmad U, Fatimi SH, Naqvi I , et al. Modified Blalock-Taussig shunt: immediate and short-term follow-up results in neonates. Heart Lung Circ 2008; 17 (1) 54-58
• 16 Yuan SM, Shinfeld AS, Raanani E. The Blalock-Taussig shunt. J Card Surg 2009; 24 (2) 101-108