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Eur J Cardiothorac Surg 2005;28:56-60
© 2005 Elsevier Science NL

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

^a German Pediatric Heart Institute, Sankt Augustin, Germany
^b German Heart Institute Berlin, Berlin, Germany

Received 29 December 2004; received in revised form 14 February 2005; accepted 31 March 2005.

^* Corresponding author. Address: Deutsches Kinderherzzentrum Sankt Augustin, Arnold Janssen-Strasse 29, 53757 Sankt Augustin, Germany. Tel.: +49 2241 249603; fax: +49 2241 249 602. (Email: photiadis{at}gmx.de).

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) 3.3mm²/kg (group 1) and 10 with NSA<3.3mm²/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±0.8mmHg (P<0.001), higher urinary output of 6.2±0.5 versus 4.2±0.5ml/kg per h (P<0.01), lower CAP of 8±0.3 versus 10±0.4mmHg (P<0.001), and lower heart rate of 145±2.6 versus 160±1.6bpm were recorded than for group 2. In group 1, lower doses of adrenaline (0.03±0.01 versus 0.15±0.01µg/kg per min, P<0.05) and noradrenaline (0.01±0.01 versus 0.13±0.04µg/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.

Key Words: Norwood operation • Shunt size • Hemodynamics • CHD • Hypoplastic left heart

Abbreviations: CAP = common atrial pressure • CO₂ = carbon dioxide • CPB = cardiopulmonary bypass • DILV = double inlet left ventricle • DKS = Damus–Kaye–Stansel operation • ECMO = extracorporeal membrane oxygenation • FiO₂ = fraction inspired oxygen • HLHS = hypoplastic left heart syndrome • IAA = interrupted aortic arch • LV = left ventricle • MAP = mean arterial pressure • MBTS = modified Blalock–Taussig shunt • MV = mitral valve • NO₂ = nitrogen • NSA = normalized shunt area, defined as cross-sectional shunt area divided by patient's body weight • PVR = pulmonary vascular resistance • Qp/Qs = pulmonary to systemic blood flow ratios • SaO₂ = arterial oxygen saturation • SvO₂ = central venous oxygen saturation • SVR = systemic vascular resistance • TA = tricuspid atresia

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