DOI: 10.1016/j.athoracsur.2007.06.067 2007;84:2070-2075 Ann Thorac Surg

Baumgartner and Duke E. Cameron D. Patel, Akhil K. Seth, Diane E. Alejo, Vincent L. Gott, Luca A. Vricella, William A.

Jason A. Williams, Anshuman K. Bansal, Bradford J. Kim, Lois U. Nwakanma, Nishant Two Thousand Blalock-Taussig Shunts: A Six-Decade Experience

http://ats.ctsnetjournals.org/cgi/content/full/84/6/2070located on the World Wide Web at:

The online version of this article, along with updated information and services, is

Print ISSN: 0003-4975; eISSN: 1552-6259. Southern Thoracic Surgical Association. Copyright © 2007 by The Society of Thoracic Surgeons.

is the official journal of The Society of Thoracic Surgeons and theThe Annals of Thoracic Surgery

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wo Thousand Blalock-Taussig Shunts:Six-Decade Experience

ason A. Williams, MD, Anshuman K. Bansal, BS, Bradford J. Kim, BA,ois U. Nwakanma, MD, Nishant D. Patel, BA, Akhil K. Seth, BS, Diane E. Alejo, BA,incent L. Gott, MD, Luca A. Vricella, MD, William A. Baumgartner, MD, anduke E. Cameron, MD

ivision of Cardiac Surgery, The Johns Hopkins Medical Institutions, Baltimore, Maryland

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Background. The Blalock-Taussig shunt (BTS) remainsaluable for palliation of congenital heart disease, but itsole has evolved. We reviewed our total institutionalxperience with BTS to examine changes in its use andutcomes.Methods. A retrospective review was performed of all

atients undergoing BTS at our institution from Novem-er 1944 to May 2006. Hospital records and autopsyecords were evaluated to determine patient demograph-cs, diagnoses, operative data, hospital complications,nd long-term outcomes.Results. During the last 62 years, 2,016 BTS were

erformed by 28 surgeons on 1,880 patients from 35ountries. Classic BTS were performed in 75% (1,503 of,016 BTS). Diagnosis was tetralogy of Fallot in 72%1,294 of 1,802), although diagnoses were imprecise in thearly part of the series. Overall operative mortality was4% (227 of 1,574). On follow-up, 32% of tetralogy of

allot patients (411 of 1,294 patients) underwent subse-

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2007 by The Society of Thoracic Surgeonsublished by Elsevier Inc

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uent total correction at our institution, and an addi-ional 116 patients for whom follow-up was availablead total correction of tetralogy of Fallot at other institu-

ions, a combined total correction of tetralogy of Fallotate of 41%. Of patients with complex congenital heartefects, 26% (106 of 404 patients) had subsequent cavo-ulmonary connection or atrial or arterial switch proce-ures. A comparison of the first and second halves of theeries revealed several trends: decreasing mean annualumber of BTS (66/year versus 9/year, respectively),ecreasing operative mortality (16% versus 9%), and

ncreasing proportion of single-ventricle diagnoses (5%ersus 34%).Conclusions. Evolution of the BTS has seen a decrease

n overall use, particularly in tetralogy of Fallot, butreater application to single-ventricle cardiac lesions andmproved operative survival.

(Ann Thorac Surg 2007;84:2070–5)

© 2007 by The Society of Thoracic Surgeons

n November 29, 1944, Dr Alfred Blalock performedthe first successful palliation of a “blue baby” with

ulmonic stenosis. Six months later, Drs Blalock andaussig submitted a report of the first surgical series for

he treatment of cyanotic heart disease involving pulmo-ary stenosis or atresia [1]. This landmark accomplish-ent was made possible by the collaboration of Alfred

lalock, Helen Taussig, and Vivian Thomas, and ulti-ately set the stage for rapid development of the field of

ardiac surgery [2].Since the 1940s, countless patients have benefited from

he shunt procedure. Although the majority of patientsad tetralogy of Fallot (TOF), this operation was quicklydapted to treat patients with a variety of cyanotic heartiseases, including tricuspid atresia, truncus arteriosus,

ransposition of the great vessels, and various forms ofingle ventricle [3–7]. Although operative techniques

ccepted for publication June 21, 2007.

resented at the Forty-third Annual Meeting of The Society of Thoracicurgeons, San Diego, CA, Jan 29–31, 2007.

ddress correspondence to Dr Cameron, Division of Cardiac Surgery,ediatric Cardiac Surgery, The Johns Hopkins Medical Institutions, 600 N

ave evolved during the past six decades, outcomesontinue to be excellent, and many patients are palliatedndefinitely or until definitive repair can be undertaken.

Our institutional experience with Blalock-Taussighunt (BTS) began with the first operation performed onileen Saxon in 1944. However, the indications andiagnoses for patients undergoing this procedure havehanged markedly since then. More than 30 years haveassed since we last reported our results with this pro-edure [6]. We sought to review our total institutionalxperience with BTS to identify changes that have oc-urred in its use and outcomes during the past sixecades.

atients and Methods

atient Selectionfter obtaining institutional review board approval andaiver of consent, retrospective review was performed of

ll patients undergoing the BTS procedure at The Johnsopkins Hospital from November 1944 through May

006. All patients who underwent some form of systemico pulmonary shunting procedure were included, regard-

ess of whether this was a part of a larger procedure or set

0003-4975/07/$32.00doi:10.1016/j.athoracsur.2007.06.067

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f procedures. The exceptions were patients undergoingentral shunts, such as Potts or Waterston shunts. The listf patients was generated from a compilation of theardiac surgery database, operative logs from the generalperating room, and personal records and archives ofrs Blalock and Taussig, which are kept in the Division ofedical Archives at our institution. Patients in whom an

nastomosis was found to be technically impossible athe time of thoracotomy or sternotomy before attemptinghe anastomosis were excluded from this study. How-ver, patients were included who expired intraopera-ively during an attempted anastomosis or who under-ent an attempted anastomosis that was found to be

echnically impossible or inadequate.

ata Collection and Patient Variablesnformation on patient demographics, diagnosis, type(s)f procedure(s), hospital complications, and long-term

able 1. Demographic and Clinical Characteristics oflalock-Taussig Shunt Cohort

ariable N (%)

aceWhite 1,630 (87)Black 110 (6)Hispanic 17 (1)Other 4 (0)Unknown 119 (6)

exMale 1,091 (58)Female 789 (42)iagnosisTetralogy of Fallot 1,294 (69)Single ventricle 160 (9)Pulmonary stenosis/atresia 83 (4)Tricuspid atresia/Epstein’s anomaly 118 (6)Transposition of the great vessels 95 (5)Other 52 (3)Unknown 78 (4)

ountry of originUnited States 1,447 (77)Canada 17 (1)France 16 (1)Other 73 (4)Unknown 327 (17)

able 2. Mean Age and Weight of Blalock-Taussig Shuntohort

peration

Mean (Median)Age at

Operation (y)

Mean (Median)Weight at

Operation (kg)

st BTS operation 8.3 (5.1) 18.9 (15.1)nd BTS operation 11.1 (7.5) 26.8 (22.9)rd BTS operation 12.7 (14.0) 52.9 (37.0)

lTS � Blalock-Taussig shunt.

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utcomes were gathered from medical records, medicalrchive documents, autopsy records, and direct patientontacts.

tatistical Analysistatistical analysis was performed using GraphPad Soft-are (GraphPad Software, Inc, Del Mar, CA) and SPSS

2.0 software (SPSS Inc, Chicago, IL). Comparisons be-ween groups were made using a two-tailed Student’s test and Fisher’s exact test as indicated. All statistics areeported as mean � standard deviation unless otherwisendicated. A probability value of less than 0.05 wasonsidered significant. Patients with missing data pointsere excluded from analysis and reporting of those data,hich accounts for the varied denominators throughout

his report. For descriptive purposes, the early part of thiseries refers to 1944 through 1969 and the late part of theeries refers to 1970 through 2006. These cutoffs werehosen arbitrarily to maintain whole decades within theroups, as well as to evaluate the era of BTS before andfter the introduction of the modified BTS technique.

esults

atientsuring the last 62 years, 2,016 BTS were performed by 28

urgeons on 1,880 patients from 35 countries. Data werevailable on 94.4% (1,774 of 1,880) of patients in thiseries. Diagnosis was tetralogy of Fallot (TOF) in 72%1,294 of 1,802), although diagnoses were imprecise in thearly part of the series. One hundred sixty patients (9%)ad single-ventricle diagnoses and typically had BTS asart of a complex palliative procedure. The percentage ofatients undergoing BTS for single-ventricle diagnosis

ncreased significantly in the late part of the series (5%ersus 34%; p � 0.0001). Tables 1 and 2 list the otherertinent demographic and clinical data for the patients

n this series.

etails of Proceduresable 3 demonstrates the volume of BTS surgery per-

ormed each decade at our institution. Notably, thennual rate of BTS performed decreased significantlyhen the early part of this series was compared with the

able 3. Procedure Details by Decade

DecadeNo. of

BTS

AnnualNo. of

BTS

MeanLOS

(days)Operative

Mortality (%)

940s 877 146 16 � 15 132 (15)950s 646 65 17 � 22 57 (9)960s 183 18 13 � 7 19 (10)970s 87 9 14 � 10 6 (7)980s 63 6 14 � 19 4 (6)990s 101 10 21 � 23 13 (13)000s 59 8 26 � 30 1 (2)

TS � Blalock-Taussig shunt; LOS � length of stay.

ate part (66/year versus 9/year; p � 0.001).

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Of 2,016 BTS procedures performed during the studyeriod, 75% (1,521 of 2,016) were classic BTS, using airect anastomosis of either the right or left subclavianrtery to the ipsilateral pulmonary artery. The modifiedTS was introduced later in the series, and typicallyntails interposition of a Gore-Tex or Dacron graft be-ween a branch pulmonary artery and either the subcla-ian artery (usually the one opposite to the aortic arch) oright brachiocephalic (innominate) artery. Figure 1 dem-nstrates the distribution of BTS procedures performedt our institution.Of all the BTS procedures, 1,610 (80%) were performed

sing direct anastomoses of the patients’ native vessels.n addition to the classic BTS, other direct anastomosesncluded anastomosis of the innominate artery to theight or main pulmonary artery, and anastomosis of theight or left subclavian artery to the main pulmonaryrtery. Prosthetic interposition conduit (Gore-Tex) wassed in 162 (8%) cases. Conduits used in the remainingrocedures included saphenous vein (n � 27), internalammary artery (n � 4), Dacron (4), subclavian artery

omograft (n � 4), and Teflon (n � 3). The type of conduitsed was unknown in 202 procedures (10%), but mostere believed to be direct anastomoses (ie, classic

hunts) as they occurred early in the series.

arly Outcomesverall operative mortality for all BTS patients was 14%

227 of 1,574). For those patients undergoing their firstTS, the operative mortality was 14% (220 of 1,595),hereas mortality for second BTS procedures was 11%

14 of 129). Six patients had a third BTS, but none died inhe perioperative period. Operative mortality for all BTSrocedures improved each decade (Fig 2), but did noteach statistical significance (p � 0.08).

Mean length of stay for all BTS in each decade arehown in Table 3. For patients undergoing their first BTS,ean postoperative length of stay was 16 � 16 days.

atients undergoing a second BTS had a mean postop-rative length of stay of 17 � 16 days, whereas patientsndergoing a third BTS had a mean postoperative lengthf stay of 15 � 9 days.Table 4 lists relevant complications after BTS com-

ig 1. Type of Blalock-Taussig shunt (BTS) procedures performed.L � left; R � right.)

ared by decade. Incidences are based on the number of F

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atients with hospital course data available (1,574 pa-ients). Of note, the incidence of prolonged intubation,epsis, and wound infection all increased in the 1990s and000s. This most likely reflects the increased complexityf patients undergoing BTS during these decades.

ate Outcomesn follow-up, 32% of TOF patients (411 of 1,294) under-ent subsequent total correction of TOF at our institu-

ion. An additional 116 patients for whom follow-up wasvailable underwent total correction of TOF at othernstitutions after BTS at our institution. The combinedotal correction of TOF rate was 41%.

Of patients with complex congenital heart defects, 26%106 of 404) had subsequent cavopulmonary connectionr atrial or arterial switch procedures. For the entire BTSohort, 850 patients (45%) are known to have undergoneultiple cardiac surgical procedures to palliate or correct

nderlying congenital cardiac lesions.Actuarial survival of the BTS cohort is shown in Figure

. This figure also demonstrates the number of patientsor whom follow-up data were available in 10-year inter-als after their original BTS. Of 710 patients known toave died after BTS, causes of death were known in 476

67%) and are depicted in Figure 4. The most commonause of death after BTS was heart failure. Cardiac arrest,troke, and brain abscesses were also common causes ofate death. Other than heart failure, the most commonause of early mortality was complications as a result ofemorrhage, although no patient has died of hemorrhage

n the last 30 years. Figure 5 depicts important trends inse and outcome of BTS during the past six decades:ecreasing mean annual number of BTS, decreasingperative mortality, and increasing proportion of single-entricle diagnoses.

omment

n the early 1970s, Taussig and colleagues [3] first re-orted long-term results of BTS at our institution. The2% operative mortality, combined with a 23% late mor-ality at 15 years, set the standard for surgical palliation ofatients with TOF. Although results were inferior foratients with tricuspid atresia [4], truncus arteriosus [5],nd transposition of the great vessels [6], the success withhese disorders nonetheless demonstrated promise forreatment of many forms of cyanotic heart disease.

ig 2. Operative mortality by decade.

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Many other groups subsequently demonstrated theffectiveness and safety of BTS for long-term palliation,egardless of patient age [8–11]. The success of the shunttems from its high patency rate, technical ease of cre-tion and takedown, low operative mortality, and lowomplication rate [9–11]. Once the BTS was demon-trated effective palliation for older children, attentionurned to younger infants and neonates. During the pasthree decades, excellent results have also been seen inewborns and infants with cyanotic heart disease, withnly modest increase in operative mortality in neonatesnd extremely low birth weight babies (�3 kg) [11–14].hese studies also demonstrated better survival whenompared with the Waterston shunt [12].

In most series, patients with TOF tend to fare betterhan patients with other forms of cyanotic heart disease.ven after Lillehei and colleagues [15] reported totalorrection for TOF in 1954, surgeons continued to use theTS for two-stage surgical repair of TOF with excellentesults (�97% long-term survival) [16, 17]. The BTS isonsidered superior to other central shunts (Waterston orotts) because of ease of takedown and less risk of

able 4. Complications Exclusive of Mortality After Blalock-T

DecadeNo. of

BTS Sepsis PneumoniaW

In

940s 877 6 (1) 11 (1)950s 647 2 (.5) 8 (2)960s 184 2 (1) 5 (4)970s 87 0 (0) 5 (8)980s 58 2 (5) 1 (2)990s 92 12 (13) 4 (4) 1000s 73 9 (16) 2 (4) 1

Bleeding requiring transfusion or reoperation.

TS � Blalock-Taussig shunt.

uig 3. Kaplan–Meier cumulative survival.

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ulmonary artery distortion and stenosis [18–20]. How-ver, as surgical techniques improved and experienceith total correction of TOF grew, surgeons have opted

oward total correction earlier in life, leaving the BTS asn option for neonates, some patients with extremely lowirth weight (�3 kg), those who are unstable at the timef presentation, or those who have anatomic issues thatitigate against early total correction [21, 22].As utility of BTS in patients with TOF has waned,

ingle-ventricle patients have become a more prominentroup of patients undergoing shunting [23, 24]. Evenhough early reports of BTS outcomes when performedn conjunction with more complex reconstruction hadperative mortalities near 30%, advancements in surgicalechniques and perioperative management have yieldedetter outcomes in recent years. Survival after Norwoodalliation using a BTS exceeds 90% in some centers [24,5]. Our data demonstrate a significantly higher propor-ion of BTS recipients now carry a diagnosis of singleentricle. That operative mortality continues to improveespite the greater percentage of single-ventricle pa-

ients is a testament to improved care in recent years. Thentroduction of the right ventricle to pulmonary arteryonduit (Sano modification) in Norwood operations hasecreased overall use of BTS in this setting, but data are

acking on comparison of the results between the two

ig 4. Causes of early and late death after Blalock-Taussig shunt for10 patients known to have experienced early or late death after

ig Shunt

Complication (%)

don Stroke Bleedinga

Prolonged Intubation(�7 days)

28 (3) 108 (13) 0 (0)18 (5) 26 (7) 0 (0)5 (4) 9 (7) 4 (3)0 (0) 2 (3) 1 (2)1 (2) 1 (2) 3 (7)

) 3 (3) 3 (3) 15 (16)) 3 (5) 2 (4) 6 (11)

auss

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5 (1)3 (1)1 (1)5 (8)3 (7)1 (127 (30

ndergoing the procedure.

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pproaches (BTS versus right ventricle to pulmonaryrtery conduit) [26–31].Another important trend highlighted by our study is

he modification in surgical technique to create a BTS.eveloped in the 1970s, the modified Blalock-Taussig

hunt using expanded polytetrafluoroethylene gainedcceptance as an alternative to the classic BTS [32–34].ost authors now consider the modified BTS to be the

echnique of choice because of four major advantagesver the classic BTS: preservation of the subclavianrtery; fewer technical problems with the anastomosis,ncluding ease of insertion and takedown; greater pul-

onary artery growth with less distortion of the pulmo-ary arteries; and lower shunt failure rate [35–37]. Me-ian sternotomy is now our preferred incision, and theodified BTS has become the standard method for

reating a systemic to pulmonary artery shunt in cyanoticnfants [38–40]; indeed, median sternotomy with the usef polytetrafluoroethylene graft has been the standardechnique at our institution since the early 1990s.

Like any retrospective study, our study has certainimitations. First, we lack standardized long-term fol-ow-up on many of our patients. This results from theigh percentage of patients from overseas countries and

he lack of social security numbers to identify and trackhe American patients in the first three decades of theeries. We also recognize that diagnoses were imprecisen the early part of this series, and many of the recordsrom the first three decades have missing data that arenrecoverable.Despite these limitations, we have shown trends in the

tilization and technique of the BTS, namely that al-hough fewer BTS are performed annually than in pre-ious decades, operative mortality has fallen despite aigher percentage of patients with single ventricle andomplex cyanotic heart disease. Our results with BTSontinue to be excellent. This procedure remains valu-ble for the palliation of many types of congenital heartisease and enjoys an important position in the history of

ig 5. Number of Blalock-Taussig shunt (BTS; gray bars) proce-ures, percentage of operative mortality (dashed line), and percent-ge of single-ventricle patients (solid line) by decade.

he evolution of our surgical specialty.

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he authors would like to thank Andrew Harrison, NancycCall, Phoebe Evans Letocha, and Marjorie Winslow-Kehoe at

he Department of Medical Archives at the Johns Hopkinsedical Institutions for their assistance with this manuscript.e are also indebted to Barbara Dobbs and Barbara Fleischman

n the Cardiac Data Center for their technical assistance. Thistudy was supported by the Joyce Koons Family Cardiac Endow-ent Fund, the Mildred and Carmont Blitz Cardiac Research

und, the Irene Piccinini Cardiac Surgery Research Endowment,nd the Hugh R. Sharp Cardiac Surgery Research Fellowship.

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ISCUSSION

R DENTON A. COOLEY (Houston, TX): Well, thank you, Drilliams, for this interesting study, and it certainly brings to

ight some of the sequences and consequences of that earlyistoric operation in November 1944. I was privileged to be on

he original team and certainly cherish the memory. I havelways believed that that was the dawn of the modern era ofardiac surgery, and I was privileged to be present to witness theeginning. It has been interesting to see the evolution andhanges technically in the procedure. The concept, of course, hasemained pretty much the same, that is, a systemic-to-ulmonary shunt. I think the big revolution has come in the last0 years with the development of synthetic graft prostheses,hich make it possible for the surgeon to select not only the

ength but also the diameter of the shunt and to try to estimatend predict the volume of the shunt involved. I know in some ofur early trepidations we had much difficulty in all of thoseespects. For example current techniques do not require sacrificef brachiocephalic tributaries.I have noticed in our own Texas Children’s Hospital that there

t is probably a larger series than you report from Hopkins, butt is an integral part of our palliative treatment of congenitaleart disease. It is interesting to me to also note that it may evenave use as a destination therapy. Just last week I saw a patient

hat I had operated on in 1956 with a classic Blalock-Taussigperation for tricuspid atresia. This patient has gone throughirthing deliveries on two occasions uneventfully and now is aery active grandmother; however, she is facing the possibilityf a cardiac transplantation. Nevertheless, the classic Blalockhunt is still continuing to function. So some of these patientsith very complex congenital anomalies, particularly single-

entricle anomalies, where there is such a strong effort toonvert every one of them to a Fontan type of physiology, somef them probably could enjoy a reasonably comfortable life withothing more than the modified Blalock-Taussig operation.Thank you very much Dr Williams and your colleagues atopkins, and I compliment you on this very interestingresentation.

R WILLIAMS: Thank you for your kind comments.

by on June 4, 2013 als.org

DOI: 10.1016/j.athoracsur.2007.06.067 2007;84:2070-2075 Ann Thorac Surg

Baumgartner and Duke E. Cameron D. Patel, Akhil K. Seth, Diane E. Alejo, Vincent L. Gott, Luca A. Vricella, William A.

Jason A. Williams, Anshuman K. Bansal, Bradford J. Kim, Lois U. Nwakanma, Nishant Two Thousand Blalock-Taussig Shunts: A Six-Decade Experience

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