Sasikumar Navaneetha, Hermuzi Antony, Fan Chun-Po Steve, Lee Kyong-Jin, Chaturvedi Rajiv, Hickey Edward, Honjo Osami, Van Arsdell Glen S, Caldarone Christopher A, Agarwal Arnav, Benson Lee
Department of Pediatrics, The Labatt Family Heart Center, Division of Cardiology, The University of Toronto School of Medicine, Toronto, Canada.
Congenit Heart Dis. 2017 Dec;12(6):808-814. doi: 10.1111/chd.12516. Epub 2017 Jul 24.
Mortality associated with the modified Blalock-Taussig shunt (MBTS) remains high despite advanced perioperative management. This study was formulated to provide data on (1) current indications, (2) outcomes, and (3) factors affecting mortality and morbidity.
A retrospective single center chart review identified 95 children (excluding hypoplastic left heart lesions) requiring a MBTS. Mortality and major morbidity were analyzed using the Kaplan Meier method and risk factor analysis using Cox's proportional hazard regression.
Median age was 8 (0-126) days, weight 3.1(1.7-5.4) kg. Seventy-three percent were neonates, 58% duct dependent and 73% had single ventricle physiology. Ninety-seven percent had a sternotomy approach for shunt placement with 70% receiving a 3.5 mm graft. Mean graft index (shunt cross sectional area [mm ]/BSA [m ]) was 44.39 ± 8.04 and shunt size (mm) to body weight (kg) ratio 1.1 ± 0.2. Hospital mortality was 12%, with an interval mortality of 6%. Shunt thrombosis/stenosis occurred in 23% and pulmonary over circulation in 30%, while shunt reoperation was required in 12% and catheter intervention in 8% of the cohort. At 1-year, survival was 82.0% (95% CI [72.7%, 88.4%]), and survival free of major morbidity 61.4% (95% CI [50.7%, 70.5%]). Duct dependency predisposed to mortality (P = .01, HR 6.74 [1.54, 29.53]) and composite outcome (mortality and major morbidity) (P = .04, HR 2.15, CI [1.036, 4.466]) and higher graft index to mortality (P = .005, HR 1.07 [1.02, 1.12]).
The commonest indication for a MBTS in the current era was single ventricle palliation. Morbidity and mortality was considerable, partly explained by the higher at risk population. Alternative methods to maintain pulmonary blood flow in place of a MBTS requires further investigation.
尽管围手术期管理先进，但改良布莱洛克 - 陶西格分流术（MBTS）相关的死亡率仍然很高。本研究旨在提供关于（1）当前适应症、（2）结局以及（3）影响死亡率和发病率的因素的数据。
一项回顾性单中心病历审查确定了95名需要MBTS的儿童（不包括左心发育不全病变）。使用Kaplan - Meier方法分析死亡率和主要发病率，并使用Cox比例风险回归进行风险因素分析。
中位年龄为8（0 - 126）天，体重为3.1（1.7 - 5.4）千克。73%为新生儿，58%依赖动脉导管，73%具有单心室生理特征。97%采用胸骨切开术进行分流置入，70%接受3.5毫米移植物。平均移植物指数（分流横截面积[mm²]/体表面积[m²]）为44.39 ± 8.04，分流尺寸（mm）与体重（kg）之比为1.1 ± 0.2。医院死亡率为12%，随访期死亡率为6%。分流血栓形成/狭窄发生率为23%，肺过度循环发生率为30%，队列中12%需要再次进行分流手术，8%需要导管介入。1年时，生存率为82.0%（95%可信区间[72.7%，88.4%]），无主要发病的生存率为61.4%（95%可信区间[50.7%，70.5%]）。依赖动脉导管易导致死亡（P = 0.01，风险比6.74[1.54，29.53]）和复合结局（死亡和主要发病）（P = 0.04，风险比2.15，可信区间[1.036，4.466]），且移植物指数越高，死亡风险越高（P = 0.005，风险比1.07[1.02，1.12]）。
当前时代MBTS最常见的适应症是单心室姑息治疗。发病率和死亡率相当高，部分原因是高危人群比例较高。替代MBTS维持肺血流的方法需要进一步研究。
