Double outlet right ventricle and pulmonary atresia with a birth weight of 1092 g

A premature infant with double outlet right ventricle and pulmonary atresia with a birth weight of 1092 g is reported. He underwent right modified Blalock-Taussig (RMBT) shunt with an expand-polytetrafluoroethylene (ePTFE) tube of 3.0 mm in diameter between the right subclavian artery and the right pulmonary artery through right thoracotomy. Eleven days later, he had to undergo central shunt between the innominate artery and the main pulmonary trunk due to poor pulmonary blood flow. Soon after the central shunt, severe heart failure occurred due to excessive pulmonary blood flow. RMBT division was performed immediately. He finally attained definitive repair at 17 months of age. Postoperative course was uneventful and he was discharged on the 17th postoperative day.     

Wrapping operation for Stanford type A acute dissecting aneurysms]

Four cases of Stanford type A acute aortic dissection were treated by wrapping operation. After careful dissection between the dilated ascending aorta and right pulmonary artery, 8 mm woven Dacron vascular prosthesis was passed around the aorta and tightened. Further enforcement wrapping was carried out using several prostheses from aortic root to the innominate artery. We call this technique "wrapping operation". Emergent operations were performed on all patients because of cardiac tamponade, 6.8-33 hours after the onset of dissection. Three patients are doing well 17-39 months after the operation, but only 1 patient died early postoperative period because of DIC and multiple organ failure. And 2 patients was showed closure of entry of the ascending aorta by the postoperative aortography. We think that the wrapping operation is a useful technique for the patients of ruptured Stanford type A acute dissecting aneurysms.     

Blalock-Taussig shunts and modified Blalock-Taussig shunts

Between January 1981 and December 1983, 53 systemic-to-pulmonary artery shunts, Blalock-Taussig shunts (BTSs) and modified Blalock-Taussig shunts (MBTSs) were carried out either as a preliminary procedure before complete correction of heart defects or as a means of permanent palliation. Central shunts continue to pose early and late problems and we seldom use them. Fifteen patients underwent a BTS and 38 an MBTS with a 5 mm polytetrafluoro-ethylene (PTFE) graft. Their ages ranged from 3 days to 11 years; 21 patients were less than 3 months old and of these 15 had an MBTS; 36 patients were less than 1 year of age and 27 of them had an MBTS. Three patients were receiving prostaglandin at the time of surgery. The overall early hospital mortality was 5,6% (3 cases); these were babies less than 2 months old. The late mortality was 3,7% (2 cases); these deaths were not shunt-related and were in babies less than 4 months old. There were 4 cases of shunt failure (7,5%) at 6, 22, 26 and 27 months after operation; a second shunt was performed in all these patients. The 48 survivors have been followed up for an average of 23 months (range 5-41 months); 6 have already undergone a complete repair. Long-term results are difficult to assess accurately because of problems with follow-up. Eight of the 53 patients had mild congestive heart failure which responded to digitalis. Because of the reliability and excellent late patency of the PTFE prosthesis, we consider it to be superior to the Waterston shunt for relief of cyanosis in the neonate and infant and as reliable as the BTS.     

体-肺动脉分流术后早期分流失效的危险因素分析

目的分析影响体-肺动脉分流术后早期分流失效的危险因素,以提高手术效果。方法回顾性分析2002年2月至2010年12月期间沈阳军区总医院189例行体-肺动脉分流术患者的临床资料,其中男87例,女102例;年龄3个月～50(5.3±6.2)岁;体重3～56(17.7±11.0)kg。术前临床诊断为法洛四联症合并肺动脉狭窄94例,室间隔缺损合并肺动脉闭锁51例,室间隔完整的肺动脉闭锁4例,功能性单心室合并肺动脉狭窄10例,功能性单心室合并肺动脉闭锁6例,右心室双出口合并肺动脉狭窄6例,完全型大动脉转位合并肺动脉狭窄8例,完全型大动脉转位合并肺动脉闭锁10例。手术方式包括中央分流术105例,改良Blalock-Taussig分流术61例,墨尔本分流术23例。结果术后早期死亡13例(6.9%),术中发生严重低血压和心律失常12例(6.3%),术后严重低心排血量10例(5.3%),术后24 h内分流失效10例(5.3%)。单因素分析结果显示,低体重(P=0.027)、分流管直径<4 mm(P=0.025)、术中不良事件(严重低血压和心律失常,P=0.002)是24 h内分流失效的危险因素。多因素logistic逐步回归分析结果显示,术中不良事件(P=0.017)是24 h内分流失效的独立危险因素。结论对于年龄小、低体重和肺动脉发育细小的患者,术中预防严重低血压和心律失常,采用4 mm以上的分流管,可明显提高分流术后效果。     

Partial portacaval shunt: renaissance of an old concept.

BACKGROUND. Partial diversion of the portal system aims to reduce portal pressure sufficiently to prevent variceal hemorrhage but still maintain adequate hepatic portal flow. METHODS. Partial portacaval shunts were performed in 25 patients with cirrhosis with portal hypertension and esophageal varices, either as a primary procedure (n = 16) or for failure of endoscopic sclerotherapy (n = 9), with ringed polytetrafluoroethylene prostheses (8, 10, or 12 mm). RESULTS. All patients have now been followed up for at least 1 year. The operative mortality rate (2 months) was 4%. In 24 patients who survived beyond the initial perioperative period, there was no recurrence of variceal bleeding. Cumulative shunt patency (up to 4 years) is 96%. Acute encephalopathy was detected in two patients (8%), but no patients had signs of chronic encephalopathy. Intraoperative pressure measurements revealed a significant correlation between decreasing diameter of the graft and the percentage reduction of the portacaval pressure gradient. Selective angiography, performed 1 year after surgery, revealed that hepatopetal flow was maintained in 70% of patients with a 10 mm shunt. CONCLUSIONS. It is possible to achieve a partial portacaval shunt, related to the diameter of the prosthesis, that preserves hepatopetal flow in the majority of patients and is associated with a very low incidence of shunt thrombosis. This effectively prevents recurrent variceal bleeding and significant postoperative encephalopathy. The performance of subsequent orthotopic liver transplantation is not compromised. The technique is recommended, either as a primary procedure or when sclerotherapy has failed, in patients with good liver function who are unlikely to require early liver transplantation (grade A and some grade B cirrhosis).     

Absent pulmonary valve syndrome: surgical approach for the worst group included in symptomatic neonates

Absent pulmonary valve syndrome (APVS) has been classified to two groups. One is severely symptomatic infant group and the other no or slightly symptomatic. But we think that severely symptomatic group should be divided into the worst neonate group and the other. This worst group, that contains neonates who can not be weaned from the respirator after surgical intervention including corrective surgery because of severe bronchomalacia and/or peripheral bronchial stenosis, has already severe respiratory distress and needs ventilatory support while high pulmonary vascular resistance is maintained. Three patients of this group were operated on at 2, 13 and 2 days of age and there were two late hospital death. The last patient underwent ligation of main pulmonary artery (mPA) and left modified Blalock-Taussig shunt (MBTS) with phi 4 mm polytetrafluoroethylene graft and was extubated on the next day. The management of this group should aim at controlling the pulmonary regurgitation as early as possible to decrease the progressive airway obstruction and minimize pulmonary tissue damage. Ligation of mPA and MBTS can be performed without cardiopulmonary bypass and eliminates pulmonary regurgitation and controls the pulmonary blood flow less than the total correction. In the point of protecting bronchi and lung and reducing the risk of surgical intervention in critical neonatal period, ligation of mPA and MBTS can be safer and more effective operation for the worst APVS neonate than the total correction with insertion of artificial valve.     

Surgical management of critical pulmonary stenosis in the neonate

Experience with 36 consecutive neonates less than 1 month of age with critical pulmonary stenosis (PS) with intact ventricular septum was analyzed to define the role of pulmonary valvotomy and of a concomitant systemic-pulmonary shunt as well as the impact of prostaglandin E1 (PGE1) therapy in the management of this disorder. Operative procedures included pulmonary valvotomy as an isolated procedure (Group 1, N = 22), pulmonary valvotomy plus a systemic-pulmonary shunt (Group 2, N = 8), pulmonary valvotomy with PGE1 therapy (Group 3, N = 5), and one miscellaneous procedure. The hospital mortality (+/- 70% confidence limits [CL]) by treatment group was as follows: Group 1, 54% (CL, 41-67%) (12/22); Group 2, 25% (CL, 9-50%) (2/8); and Group 3, 0 (CL, 0-32%); Group 1 versus Group 2 plus Group 3 (p less than or equal to 0.05). Patients managed with a shunt or perioperative administration of PGE1 experienced a significant improvement in early survival. Late postoperative angiography demonstrated exemplary right ventricular growth in the majority of patients, although important residual abnormalities of the outflow tract necessitating operative repair were frequently present (5-year and 10-year actuarial freedom from reoperation, 73 +/- 10% and 42 +/- 16%, respectively [+/- standard error of the mean]). This review illustrates the limitations of pulmonary valvotomy as an isolated therapeutic method in neonates with critical PS. Provision of a systemic extracardiac source of pulmonary blood flow, accomplished by a systemic-pulmonary shunt or PGE1 infusion continued postoperatively, is the most important determinant of early survival in this disorder.     

Small-Diameter PTFE Portosystemic Shunts: Portocaval vs Mesocaval

Fifty-seven patients with failed sclerotherapy received a mesocaval interposition shunt with an externally supported, ringed polytetrafluoroethylene prosthesis of either 10 or 12 mm diameter. Thirty-one patients had Child-Pugh gradeA disease and 26 grade B; all had a liver volume of 1000– 2500 ml. Follow-up ranged from 16 months to 6 years 3 months. Three patients (5 per cent) died in the postoperative period. There were two postoperative recurrences of variceal haemorrhage and one recurrent bleed in the second year after surgery. The cumulative shunt patency rate was 95 per cent and the incidence of encephalopathy 9 per cent; the latter was successfully managed by protein restriction and/or lactulose therapy. The actuarial survival rate for the whole group at 6 years was 78 per cent, for those with Child-Pugh grade A 88 per cent and for grade B 67 per cent. Small-lumen mesocaval interposition shunting achieves portal decompression, preserves hepatopetal flow, has a low incidence of shunt thrombosis, prevents recurrent variceal bleeding and is not associated with significant postoperative encephalopathy.     

Pulmonary artery configuration after palliative operations for hypoplastic left heart syndrome

Pulmonary artery architecture and symmetry after palliative operations for hypoplastic left heart syndrome may affect subsequent suitability for a modified Fontan operation. Two-dimensional echocardiography was used to measure pulmonary artery diameter and assess symmetry after two types of systemic-pulmonary artery shunts: modified right Blalock-Taussig shunt (14 patients) and central shunt (from underside of aortic arch gusset to pulmonary artery confluence) (14 patients). Age, weight, preoperative diameter of right and left pulmonary arteries (proximal, middle, and distal segments), and mean interval between preoperative and postoperative echocardiographic studies (20.2 +/- 4.4 days in the Blalock shunt group; 19.1 +/- 6.8 days in the central shunt group) were similar. Early postoperatively, patients with a Blalock shunt showed a significant decrease in the diameter of all pulmonary artery segments except the distal right pulmonary artery. The diameters tapered from distal right to distal left pulmonary artery in this group. Patients with the central shunt had a significant decrease in the diameter of all pulmonary artery segments. There were no significant differences when cross comparisons were made of the various pulmonary arterial segments in patients after a central shunt. Similar findings persisted in 19 patients from both groups who had a late postoperative echocardiogram (mean interval between studies = 271 days in the group of 10 patients with Blalock shunt and 167 days in the group of nine patients with a central shunt). In conclusion, the central shunt preserves pulmonary artery symmetry, which may be important in candidates for the Fontan operation in infancy.     

Hemodynamics of the interposition mesocaval shunt.

Eighty interposition mesocaval shunts, using a knitted Dacron large diameter prosthesis, have been performed during the past five and one-half years. Patients were evaluated from the standpoint of protection from recurrent esophageal hemorrhage, shunt patency, encephalopathy and cumulative survival analysis. In a selected group of patients, hemodynamic measurements were also obtained in the pre, intra, and postoperative periods. These included measurements of wedged hepatic vein pressure, superior mesentric venous blood flow, and residual superior mesenteric, hepatic sinusoidal and inferior vena cava pressures following the shunt procedure. Additionally, direct shunt flow measurements utilizing a square wave of electromagnetic flowmeter were also performed. Results indicate that the shunt patency is 95%; adequate decompression of the portal system was accomplished; recurrent variceal hemorrhage did not occur if the shunt remained patent; the incidence of encephalopathy was low (11%); and the operative mortality for the entire series was 9%. Continued perfusion of the liver was documented in 44% of patients and appears to be a function of the residual total portal resistance largely controlled by inferior vena caval pressure at the level of graft replacement. Life survivhat the interposition mesocaval shunt appears to be an effective technique for the control of variceal hemorrhage, has important hemodynamic advantages and can be applied to most patients for the control of variceal hemorrhage due to portal hypertension.     

Feasibility of reversible pulmonary artery banding: early results and intermediate-term follow-up

Development of a reversible pulmonary artery band might obviate the need for a second cardiac surgical procedure in children with some forms of congenital heart disease. We evaluated a segmented Silastic-coated Dacron mesh band 2 to 4 mm wide sewn together with absorbable 2-0 polydioxanone suture for use as a reversible pulmonary artery band. Nine puppies 6 to 8 weeks old (mean weight, 5.8 kg) underwent placement of this pulmonary artery band. All survived the operation with a mean initial systolic gradient of 6.5 +/- 1.6 mm Hg and underwent cardiac catheterization at monthly intervals for 3 months. Two puppies died of right ventricular failure. The remaining puppies underwent balloon angioplasty with balloons 20 to 25 mm in diameter. No complications resulted from balloon angioplasty, but 1 puppy died 24 hours later of unidentified causes. Balloon angioplasty decreased the mean gradient from 46.7 +/- 6.8 mm Hg to 6.7 +/- 2.6 mm Hg. Angiography showed an increase in mean diameter of the site of the pulmonary artery band from 5.2 +/- 1.0 to 10.8 +/- 1.7 mm Hg. There was no evidence of vessel injury on angiograms. Fourteen months after balloon angioplasty, the mean gradient was 22.3 +/- 17.0 mm Hg. Our data demonstrate that a functionally reversible pulmonary artery band constructed of segmented Silastic-coated Dacron mesh and 2-0 polydioxanone suture is feasible.     

Surgical Closure of the Patent Ductus Arteriosus with an Intravascular Prosthesis: Clinical Experience

The authors developed a new prosthesis for patent ductus arteriosus (PDA) closure, using a delivery device inserted through the main pulmonary artery (MPA) avoiding ductal dissection and use of cardiopulmonary bypass. The prosthesis was inserted in 19 consecutive patients between 1985 and 1992. They have been followed for a mean of 4.8 years (minimum 30 days, maximum 7.5 years). There were 14 women (72%) and the average age was 11 years (16 months to 38 years). All patients presented with pulmonary hypertension (4 severe, 5 moderate, and 10 mild). Simultaneous surgical procedures for congenital heart disease were performed in two cases. One patient had a diffuse calcified PDA. The average diameter of the inserted prosthesis was 7.5 mm (3.5 to 12.5 mm). Neither hemorrhage nor prosthesis dislocation/embolization occurred during the implantation or in the postoperative period. In a newborn (30 days) with severe cardiomegaly and thin MPA, we decided to ligate the ductus. Chronic cor pulmonale contributed to death in one patient 3.7 years after operation. The remaining patients recovered well, without clinical evidence of residual shunt. Therefore, we recommend the use of this new prosthesis for PDA closure in cases of large ductus or ductus complicated with calcification, pulmonary hypertension, and when associated open heart surgery is required. (J Card Surg 1994;9:343–347)     

婴儿早期法洛四联症的外科治疗

目的总结婴儿早期法洛四联症（TOF）外科治疗经验,探讨TOF早期根治术的相关问题。方法回顾性分析上海市儿童医院2008年6月至2010年8月收治21例婴儿早期（〈6个月）TOF患者的临床资料,其中男14例,女7例;年龄4.86±1.15个月;体重6.84±1.33 kg。均经心脏彩色超声心动图确诊,有4例行CT或磁共振成像（MRI）或右心导管造影术。McGoon比值1.86±0.41,肺动脉指数（PAI）142.54±59.46 mm2/m2。经右心房（19例）或右心室（2例）自体心包补片连续缝合修补室间隔缺损;对肺动脉瓣环Z值〈-1者采用心包补片跨瓣扩大成形（18例）;对接近或基本达到正常Z值者保留瓣环,用心包补片分别扩大右心室流出道（RVOT）和肺总动脉（3例）。结果术后第15 d因心力衰竭死亡1例;1例术后第2 d拔除气管内插管后出现喉头水肿,再插管辅助通气,3 d后顺利撤机;其余患者术后均顺利恢复。18例获得随访,随访9.89±6.47个月,心功能改善（Ross分级Ⅰ~Ⅱ级）;随访心脏超声心动图提示：RVOT压差为21.20±12.27 mm Hg（8.10~45.14 mm Hg）;肺动脉瓣反流（PI）轻度10例,中度5例,无重度患者;2例早期残余室间隔缺损已闭合。与术后早期相比,RVOT压差和PI程度差异均无统计学意义（P〉0.05）,右心功能良好。结论婴儿早期行TOF根治术可取得良好的手术效果;经右心房矫正心内畸形,并保留肺动脉瓣环有利于术后心功能保护。     

Repair of ventricular septal defect after pulmonary artery banding.

Since 1964, 90 patients have undergone two-stage surgical repair of ventricular septal defect (VSD) with pulmonary artery banding (PAB) in early infancy and total repair at an average age of 4 years. Reconstruction of the pulmonary artery was accomplished with a pericardial patch, woven Dacron patch, or transverse angioplasty. The VSD was closed with a knitted Dacron patch in 75 patients and by primary suture technique in 13 patients. The VSD closed spontaneously in 2 patients. The mortality rate for patients who had repair and debanding was 9 per cent (8 patients), including 4 deaths due to severe pulmonary hypertensive disease, 3 from congestive heart failure, and one from atrioventricular block. Twenty patients underwent repeat cardiac catheterization several months to 7 years after total repair. This study revealed no shunt in 16 patients and a minimal shunt not requiring operation in the other 4 children. Slight residual stenosis of the pulmonary artery was found in 2 patients and a residual infundibular stenosis in another 2 patients. We believe two-stage surgical treatment of VSD in severely ill infants under one year of age is safe and reliable.     

6个月以下婴儿法洛四联症的外科治疗

目的探讨小婴儿法洛四联症（TOF）的最佳手术时机,以提高外科手术疗效,降低手术死亡率。方法回顾性分析我科1996年10月至2006年12月收治的108例6个月以下TOF婴儿的临床资料,其中男70例,女38例;年龄9 d~6个月,平均年龄4.70个月。108例患者中行TOF根治术104例,体动脉-肺动脉分流术4例;其中行急诊手术5例。结果手术死亡5例,死亡率4.63%,死于低心排血量综合征3例,肺部感染、左肺发育不全导致急性呼吸窘迫综合征（ARDS）1例,急性坏死性肠炎1例。随访82例,随访时间31.17±40.00个月;失访21例。随访期间无远期死亡,1例患者术后6个月因肺动脉狭窄行二次手术矫治,平均再手术率为0.92%;其余患者心功能（NYHA）Ⅰ~Ⅱ级,超声心动图提示：室间隔无残余分流,右心室流出道和肺动脉瓣无明显狭窄,跨瓣压差小于50mm Hg。结论对6个月以下的小婴儿早期行TOF根治术是可行的,手术死亡率是可以接受的。     

Open stent grafting for abdominal aortic aneurysm in a patient with a severely calcified abdominal aorta

We describe a 74-year-old male who underwent open stent repair for an infrarenal abdominal aortic aneurysm with a severely calcified aortic neck. The stent graft was constructed by covering a 50-mm long Gianturco Z stent (diameter: 20 mm) with a Dacron prosthesis (diameter: 20 mm). The stented Dacron graft was inserted into the calcified aortic neck, was then sutured to the trimmed aneurysmal wall, and was anastomosed to a bifurcated prosthesis. The distal ends of the bifurcated prosthesis were anastomosed to both common femoral arteries, and the terminal aorta was closed. The patient had an uneventful postoperative course. This procedure may be a feasible and safe way to repair infrarenal abdominal aortic aneurysm with a severely calcified aortic neck.     

The Blalock-Taussig Shunt in the First Two Years of Life: A Safe and Effective Procedure

Many surgeons have been reluctant to perform Blalock shunts in patients who are in infancy or early childhood (< 24 months old) and have done instead direct aortopulmonary anastomoses. Recently, others have advocated complete repair of tetralogy of Fallot in early infancy because of the high mortality of direct aortopulmonary shunts. We believe the Blalock-Taussig anastomosis is a safe and effective palliative procedure for all infants with inadequate pulmonary blood flow regardless of size.During the past nine years, 24 babies less than 2 years old who were followed had construction of Blalock-Taussig anastomosis for inadequate pulmonary blood flow. There were no operative deaths and no shunt-related late deaths. Of the 24 babies, 12 were less than 12 months old. Eighteen of the 24 had tetralogy of Fallot. The remaining 6 had a variety of lesions with inadequate pulmonary blood flow. The mean weight of the entire group was 7.3 ± 1.6 kg. Of those infants less than 12 months old, the mean weight was 6.8 ± 2.0 kg. More than 6 months following construction of the shunt, 2 babies died from sepsis unrelated to cardiovascular status. All infants had adequate but not excessive pulmonary blood flow after shunting. There were no late shunt failures.     

The prosthetic (Teflon) central aortopulmonary shunt for cyanotic infants less than three weeks old: results and long-term follow-up

The expanded microporous polytetrafluoroethylene (PTFE) 4 mm vascular prosthesis has been used to create a central aortopulmonary shunt in 20 critically ill infants less than 3 weeks old. The infants ranged from 1 to 18 days old (5.25 days), and from 1.5 to 4.0 kg (2.9 kg). Conduit length ranged from 2 to 6 cm (4 cm). Sixteen patients had atresia of the tricuspid or pulmonary valve. There were 6 early deaths (30%), only 1 of which was shunt related. The mean preoperative arterial oxygen saturation was 62% (range, 33 to 80%), and mean postoperative saturation was 87% (range, 78 to 90%). There were 5 late deaths, 1 probably caused by shunt failure. Nine long-term survivors have done well. Follow-up ranges from 1 to 36 months (18 months). Factors influencing conduit function are length, technical considerations, and pulmonary vascular resistance. Late restudy in 5 of 9 survivors confirms patency and demonstrates bidirectional pulmonary blood flow. Since PTFE shunt flow capability is fixed, the infant may require repair or a second shunt within 24 months of the initial procedure.     

Does size matter? Larger Blalock-Taussig shunt in the modified Norwood operation correlates with better hemodynamics.

OBJECTIVE: Excess pulmonary to systemic blood flow ratio (Qp/Qs) correlates with hemodynamic instability and mortality after modified Norwood operation. Studies suggest that maximal oxygen delivery occurs at a Qp/Qs of around 1. The use of a rather small modified Blalock-Taussig shunt (MBTS) is believed to achieve this goal. However, optimal MBTS size with respect to postoperative hemodynamics remains unclear. METHODS: Between 2/2002 and 2/2004, 20 consecutive patients underwent Norwood operation; there were 19 operative survivors: nine with a normalized MBTS area (NSA) > or = 3.3 mm2/kg (group 1) and 10 with NSA < 3.3 mm2/kg (group 2). Mean arterial pressure (MAP) and common atrial pressures (CAP), arterial and superior vena cava oxygen saturations, urinary output and inotropes recorded for the postoperative hours 0, 6, 12, 18, 24 and 48 were analyzed. RESULTS: Hospital mortality was 11.1% (1/9) in group 1 and 30% (3/10) in group 2 (P = 0.6). For group 1 significantly higher MAP of 52+/-1.3 versus 46+/-0.8 mmHg (P < 0.001), higher urinary output of 6.2+/-0.5 versus 4.2+/-0.5 ml/kg per h (P < 0.01), lower CAP of 8+/-0.3 versus 10+/-0.4 mmHg (P < 0.001), and lower heart rate of 145+/-2.6 versus 160+/-1.6 bpm were recorded than for group 2. In group 1, lower doses of adrenaline (0.03+/-0.01 versus 0.15+/-0.01 microg/kg per min, P < 0.05) and noradrenaline (0.01+/-0.01 versus 0.13+/-0.04 microg/kg per min, P < 0.01) were needed. Although Qp/Qs was more often calculated to be > 1.5 in group 1 (51 versus 31%), arteriovenous oxygen difference and oxygen excess factor were not significantly different, indicating similar oxygen delivery. CONCLUSIONS: Monitoring of the central venous oxygen saturations and application of afterload reduction in cases of high Qp/Qs allows the insertion of a larger MBTS without association with lower oxygen delivery. In fact, better hemodynamic status with less inotropic support was noted with a larger MBTS early after Norwood operation.     

Right pulmonary artery development after modified Blalock-Taussig shunt (MBTS) in infants with pulmonary atresia, VSD and confluent pulmonary arteries

The ideal palliation for infants with pulmonary atresia, ventricular septal defect and confluent pulmonary arteries should promote normal development of the pulmonary artery branches. In 26 patients who survived a modified Blalock-Taussig shunt (MBTS) in the first year of life, the right pulmonary artery was measured before and after operation by two dimensional (2D) echocardiography. In each patient its size was compared to the normal value for the same body surface area. The patients were divided according to this ratio and according to the real size (mm). Although increased in all cases but two, the size of the right pulmonary artery remained remarkably less than normal in patients with an initially small right pulmonary artery. In view of these results, early palliative enlargement of the right ventricular outflow tract is probably advisable in infants with diminutive pulmonary arteries who do not show adequate pulmonary branch development after MBTS.