Bove Thierry, Vandekerckhove Kristof, Panzer Joseph, De Groote Katya, De Wolf Daniel, François Katrien
Department of Cardiac Surgery, University Hospital of Ghent, Ghent, Belgium
Department of Pediatric Cardiology, University Hospital of Ghent, Ghent, Belgium.
World J Pediatr Congenit Heart Surg. 2015 Jan;6(1):67-74. doi: 10.1177/2150135114558690.
Albeit being a simple surgical procedure, adverse outcomes with the modified Blalock-Taussig shunt (MBTS) are commonly reported in generalizing terms, independent of the underlying heart disorder.
From August 1995 to December 2013, a total of 150 children underwent an MBTS for tetralogy of Fallot (TOF; n = 44, 29%), pulmonary atresia with ventricular septal defect (PA/VSD; n = 28, 19%), pulmonary atresia with intact ventricular septum (PA/IVS; n = 17, 11%), transposition of the great arteries with ventricular septal defect (TGA/VSD) with pulmonary stenosis (PS; n = 12, 8%), Ebstein malformation (n = 2, 1%), and complex univentricular anomalies (n = 47, 31%). Outcome analysis focused on operative mortality and survival until shunt takedown, adjusted to the underlying disease.
In-hospital mortality was 8.7% (n = 13), and interstage mortality was 5.1% (n = 7), resulting in 86.1% survival to the next surgery. Hospital mortality was 14% in PA/VSD, 13% in univentricular heart, and 18% in PA/IVS, while no mortality was observed in TOF, TGA/VSD/PS, and Ebstein disease. A shunt-related complication was observed in 18% (n = 27) of the children, including acute thrombosis (n = 7, 5%), shunt stenosis (n = 3, 2%), overshunting (n = 7, 5%), and pulmonary artery stenosis (n = 10, 7%). Multivariate analysis of shunt-dependent time survival identified a shunt complication occurring in a univentricular circulation (hazard ratio [HR] 4.10, 95% confidence interval [CI] = 1.05-17.43, P = .01) and increased shunt size-to-weight ratio (HR 2.72, 95% CI = 0.80-9.18, P = .04) as risk factors. Shunt thrombosis was also a negative outcome predictor in PA/VSD, when requiring associated unifocalization (P = .05).
This study shows that the outcome of palliation with the MBTS is importantly affected by the occurrence of a shunt-related complication, whose circulatory effect is even more dismal in single ventricle hearts. Since an increased shunt size-to-weight ratio additionally compromises the shunt-dependent survival, it emphasizes that the choice of the shunt with regard to size as well as surgical approach remains critical.
尽管改良布莱洛克 - 陶西格分流术（MBTS）是一种简单的外科手术，但关于该手术的不良后果通常是笼统报道，且未考虑潜在的心脏疾病。
1995年8月至2013年12月，共有150例儿童接受了针对法洛四联症（TOF；n = 44，29%）、室间隔缺损合并肺动脉闭锁（PA/VSD；n = 28，19%）、室间隔完整的肺动脉闭锁（PA/IVS；n = 17，11%）、大动脉转位合并室间隔缺损（TGA/VSD）及肺动脉狭窄（PS；n = 12，8%）、埃布斯坦畸形（n = 2，1%）和复杂单心室畸形（n = 47，31%）的MBTS手术。结局分析聚焦于手术死亡率和直至分流拆除时的生存率，并根据潜在疾病进行调整。
住院死亡率为8.7%（n = 13），分期死亡率为5.1%（n = 7），86.1%的患者存活至下次手术。PA/VSD患者的住院死亡率为14%，单心室心脏患者为13%，PA/IVS患者为18%，而TOF、TGA/VSD/PS和埃布斯坦病患者未观察到死亡。18%（n = 27）的儿童出现了与分流相关的并发症，包括急性血栓形成（n = 7，5%）、分流狭窄（n = 3，2%）、过度分流（n = 7，5%）和肺动脉狭窄（n = 10，7%）。对依赖分流的生存时间进行多因素分析发现，单心室循环中出现分流并发症（风险比[HR] 4.10，95%置信区间[CI] = 1.05 - 17.43，P = .01）以及分流大小与体重比值增加（HR 2.72，95% CI = 0.80 - 9.18，P = .04）是风险因素。在PA/VSD患者中，当需要进行相关单灶化手术时，分流血栓形成也是不良结局的预测因素（P = .05）。
本研究表明，MBTS姑息治疗的结局受到与分流相关并发症发生情况的重要影响，在单心室心脏中其循环效应更差。由于分流大小与体重比值增加会进一步影响依赖分流的生存率，这强调了分流大小的选择以及手术方式仍然至关重要。
