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NEONATAL SHUNT OPERATIONS

¹ Department of Cardiovascular Surgery, Gazi University Medical Faculty, Ankara, Turkey, Tel: 90 505 319 3190, Fax: 90 312 202 9014, Email: dilekerer{at}yahoo.com
² Department of Cardiology, Lodz University Medical Faculty, Lodz, Poland
³ Department of Cardiovascular Surgery, Istanbul Medical Faculty, Istanbul University, Istanbul, Turkey

We read with interest the manuscript by Swain et al.¹ in which they present their peri- and postoperative experiences with the treatment of neonatal patients who have undergone modified Blalock-Taussig (mB-T) shunt operation. The authors have successfully managed these critical cases of the pediatric cardiac surgery.¹ However, we believe their manuscript contains certain points to be stressed on.

In very small caliber pulmonary arteries and low birth weight neonates, shunt anastomosis between subclavian artery and the branch pulmonary artery constitutes several difficulties.^1–5 Additionally the potence of these shunts on the pulmonary arterial growth is limited. Thus, many authors recommend median sternotomy and anastomosis of the main pulmonary artery to the ascending aorta or the aortic arch directly or with the help of a graft material.^2–5

The authors preferred to perform classical mB-T shunt operation with their surgical anastomosis modification which has been successful in their mid-term results.¹ It would be helpful if the authors could support their data with a long term follow up angiography.

During and after the surgery, the authors preferred heparinization. It is well known that in newly born babies, the clotting properties of the blood is not very well developed.⁶ It is also the case in case of cardiac failure. Have the authors performed bleeding and clotting studies before surgery? What was the total amount of blood and blood product usage during and after surgery? Are the operations delayed because of bleeding? What was the mean operative duration?

Another issue is the blood pressure of the patients. It would be helpful to present the blood pressure data in a separate table. Moreover, we believe demonstration of pressure drop, especially for diastolic pressure, is mandatory since authors preferred to use 4 mm grafts majorly, which is relatively large according to the literature¹ and when the weights of their patients are taken into consideration. On the other hand, a 4-mm shunt graft may not be important in the palliation of a Tetralogy of Fallot case; however, it is critical for the patients presenting single ventricle pathology. Authors lost some patients postoperatively. Has an influence between graft size and mortality been predicted? What were the diagnoses of mortality occurring patients?

A bigger shunt graft definitely provides better oxygenation and, as the authors state, safer follow up for longer terms.¹ However, it accounts for the risk of cardiac failure. Could the authors explain their postoperative medications in detail especially after the cessation of inotropic support? How many were on diuretic and digoxin therapy? Has there been a relation detected between the size of the graft and anticongestive therapy?

One last comment from our side, the literature referred to in the authors manuscript are relatively old.¹ It would be helpful for readers if recent literatures were cited.

In conclusion, we congratulate the authors for their successful modification, however, the issues above seem to be mandatory to be explained from our point of view.

REFERENCES

1. Swain SK, Dharmapuram AK, Reddy P, Ramdoss N, Raghavan SS, Kona SM. Neonatal Blalock-Taussig shunt: technical aspects and postoperative management. Asian Cardiovasc Thorac Ann 2008;16:7–10.[Abstract/Free Full Text]

2. Duncan BW, Mee RB, Prieto LR, Rosenthal GL, Mesia CI, Qureshi A, et al. Staged repair of tetralogy of Fallot with pulmonary atresia and major aortopulmonary collateral arteries. J Thorac Cardiovasc Surg 2003;126:694–702.[Abstract/Free Full Text]

3. Ugurlucan M, Ali Sayin Ö, Çinar T, Niflli K, Aydogan Ü, Tireli E, et al. Modified aortopulmonary window technique for the first-stage treatment of pulmonary atresia. Turkish J Thorac Cardiovasc Surg 2007;15:41–4.

4. Batra AS, Starnes VA, Wells WJ. Does the site of insertion of a systemic-pulmonary shunt influence growth of the pulmonary arteries? Ann Thorac Surg 2005;79:636–40.[Abstract/Free Full Text]

5. Ugurlucan M, Banach M, Tireli E. The anastomosis between aorta and extension conduit of the pulmonary artery. Interactive CardioVascular and Thoracic Surgery 2007, doi:10.1510/icvts.2007.170720A.

6. Mullen JC, Lemermeyer G, Bentley MJ. Modified Blalock-Taussig shunts: to heparinize or not to heparinize? Can J Cardiol 1996;12:645–7.[Medline]

This Article Extract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Dilek Erer Maciej Banach Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Erer, D. Articles by Ugurlucan, M. Search for Related Content PubMed PubMed Citation Articles by Erer, D. Articles by Ugurlucan, M.