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CASE REPORT
Year : 2023 | Volume
: 9
| Issue : 1 | Page : 84-86
Hybrid approach for postclassical blalock–Taussig shunt tetralogy
Vishal Agrawal1, Pankaj Garg1, Pooja Vyas2, Joshi Hasit2, Amit Mishra3
1 Department of Cardiovascular and Thoracic Surgery, U. N. Mehta Institute of Cardiology and Research Center (Affiliated to BJ Medical College), Civil Hospital Campus, Ahmedabad, Gujarat, India
2 Department of Cardiology, U. N. Mehta Institute of Cardiology and Research Center (Affiliated to BJ Medical College), Civil Hospital Campus, Ahmedabad, Gujarat, India
3 Department of Pediatric Cardiovascular and Thoracic Surgery, U. N. Mehta Institute of Cardiology and Research Center (Affiliated to BJ Medical College), Civil Hospital Campus, Ahmedabad, Gujarat, India
Correspondence Address:
Amit Mishra
Department of Pediatric Cardiovascular and Thoracic Surgery, U. N. Mehta Institute of Cardiology and Research Center, (Affiliated to BJ Medical College), New Civil Hospital Campus, Asarwa, Ahmedabad - 380 016, Gujarat
India
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/jpcs.jpcs_57_22
In developing countries, we still come across occasional patients who have undergone classic Blalock–Taussig shunt (CBTS) previously. We present a case of 23-year-old female with tetralogy of Fallot who had undergone CBTS operation at the age of 1 year and is now presented for total correction. Takedown of CBTS during surgery has catastrophic complications during looping and ligation of shunt due to extensive collateralization. We, therefore, took a hybrid approach for the patient. The CBTS was first blocked with the balloon, followed by surgical intracardiac repair, and finally, by device closure of CBTS.
Keywords: Classic Blalock–Taussig shunt, left computed tomography pulmonary angiogram, modified Blalock–Taussig shunt, right pulmonary artery, tetralogy of Fallot
In today's era classic Blalock–Taussig shunt (CBTS) has been completely replaced by the modified Blalock–Taussig shunt (MBTS). The main challenge while dealing with such patients is the looping and ligation of CBTS, as it can lead to catastrophic complications, so we adopted a strategy to occlude the CBTS by transcatheter route in a hybrid cardiac operating room. We conclude that this strategy is safe and effective.
Case ReportA 23-year-old female patient with tetralogy of Fallot (TOF) had undergone CBTS at 1 year of age. No follow-up was done thereafter and she presented now after so many years with the complaint of bluish discoloration of fingertips and lips with easy fatigability for the past 6 months. Clinical examination revealed her oxygen saturation was 72%, grade 4/6 ejection systolic murmur at the pulmonary area, and continuous murmur at the right suprascapular area. Right upper limb pulses were feeble, with a systolic pressure being 20 mmHg less than the left upper limb. Transthoracic two-dimensional echocardiogram revealed TOF with adequate size branch pulmonary artery. Patent right CBTS with turbulence at right pulmonary artery (RPA) end. Computed tomography pulmonary angiogram (CTPA) confirmed the diagnosis of tetralogy with a confluent good size branch pulmonary arteries. CTPA showed severe focal stenosis (3.5 mm) of right CBTS at the distal end and mild focal stenosis (7 mm) in the mid part [Figure 1] and there were no major aorta pulmonary collaterals. Informed consent was taken, and a hybrid approach was planned with the involvement of the cardiac catheterization team in the hybrid operating room. A 6F sheath was placed in the right femoral artery and a 6F pigtail catheter (Cordis Europa, Rodden, and Holland) was inserted into the arterial sheath over a 0.035 Terumo wire (Terumo Europe NV, Leuven, Belgium) and advanced into the aortic arch. Following the measurement of arterial pressure, an aortogram was performed and outlined a patent right CBTS. The catheter was advanced into the right subclavian artery. A further selective angiogram demonstrated the CBTS with narrowing at the distal (pulmonary) end. The narrowest region was measured at 3.5 mm [Figure 2]. The 6F pigtail catheter was exchanged for a 10 mm × 40 mm MAXI-LD balloon over 0.035 stiff Amplatz exchange length wire. This Amplatz wire was kept in RPA.
Figure 1: (a and b) Computed tomography pulmonary angiography showing right CBTS, with severe stenosis at RPA end. CBTS: Classic Blalock–Taussig shunt, RPA: Right pulmonary artery
Figure 2: Cardiac catheterization showing patent right CBTS with narrowing at RPA end. CBTS: Classic Blalock–Taussig shunt, RPA: Right pulmonary arteryUsing standard aortic and bicaval cannulation went on bypass. The balloon was inflated at 8 atm (nominal pressure). Antegrade St. Thomas cold blood cardioplegia was given. Intracardiac repair along with pulmonary valve replacement (21 mm porcine bioprosthesis) was performed after surgery. The balloon was deflated and exchanged for a 7F Amplatz delivery sheath over the same stiff wire. The delivery system was advanced into the subclavian artery, and stiff wire was removed. Following that, Amplatzer Vascular Plug II (20 mm) was screwed onto the nitinol delivery wire and pushed into a preplaced 7F Amplatzer delivery system. The final angiogram from the same delivery system confirmed occlusion of Blalock–Taussig shunt [Figure 3]. The chest was closed and the patient was shifted to the recovery room with stable hemodynamics. The postoperative course was uneventful. At 3-year follow-up, the patient is asymptomatic with echocardiography showing well-functioning pulmonary valve, no right ventricular outflow tract obstruction, and good biventricular function.
Figure 3: Amplatzer Vascular Plug II (20 mm) occluding the CBTS. CBTS: Classic Blalock–Taussig shunt Discussion The CBTS was the original shunt described by Alfred Blalock and Helen Taussig. The end-to-side anastomosis between the subclavian (or the innominate) and pulmonary arteries is performed. With the advent of prosthetic grafts, the CBTS is now completely replaced by MBTS. Post-CBTS the patients are relieved from cyanosis till they grow up due to potential growth of anastomosis and so do not present in time for a complete repair. The major disadvantages of CBTS included thrombosis, mutilation of the subclavian or the innominate artery, and significant arm ischemia from subclavian artery division.[1] However, during the final surgical repair, the looping of CBTS for ligation needs extensive dissection, which can lead to catastrophic bleeding due to extensive collateralization, especially if it is a left-side CBTS. Furthermore, there is a risk of recurrent laryngeal nerve injury, phrenic nerve injury, and Horner syndrome. Considering these potential complications, we approached with a strategy to occlude the CBTS by transcatheter route in a hybrid cardiac operating room.
We got our idea of a hybrid approach after reading the case report of Kenny and Walsh[2] in which they closed a residual CBTS with the Amplatzer Duct Occluder II following definitive surgical correction for TOF. Ni et al.[3] have described a similar hybrid approach for post-CBTS TOF repair, but they occluded the shunt completely with the device and had to go on crash cardiopulmonary bypass due to sudden desaturation. Our stepwise approach in a hybrid operating room is comparatively much safer. Sivakumar et al.[4] used the hybrid approach routinely to occlude MBTS as well, but we believe MBTS can be safely and effectively ligated/clipped directly during surgery with minimal risk. Our above-described strategy is safe, effective, time saving, and highlights the importance of having a hybrid cardiac operating room.
ConclusionAdapting to technology with advancing time to solve old problems is innovation. Although such cases are rarely encountered, the use of a hybrid approach made the situation less challenging and safer. Such hybrid operating rooms can be explored for different challenging scenarios when needed.
Ethics clearance
As Per Institute protocol, there is no requirement of EC approval for case report publication.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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