· Increase pulmonary blood flow - Aortopulmonary shunt
· Decrease pulmonary artery blood flow - PA banding
· Improve mixing - atrial septectomy
· Reduce ventricular work - Glenn shunt
· Classic Blalock-Taussig shunt - Subclavian to PA
· Modified Blalock-Taussig - Goretex subclavian to PA
· Central - Goretex ascending aorta to main PA
· Waterston - Ascending aorta to RPA
· Pott's - Descending aorta to LPA
· Brock - Pulmonary valvotomy, closed
· Tetralogy of Fallot less than age 3 months, as patient is too small for adequate reconstruction of RVOT
· Pulmonary atresia with or without VSD
· Tricuspid atresia with PS
· Single ventricle with PS
· TGA with VSD and PS; although there is good mixing at the level of the ventricle, there is inadequate pulmonary flow
· In summary, aortopulmonary shunts will benefit any patient with pulmonary obstruction
· Classic BT shunt - difficult to mobilize subclavian and PA distortion if subclavian too short
· Modified BT shunt - easy, less PA distortion, more growth of the pulmonary arteries
· Pott's - pulmonary vascular disease from oversized shunt
· Waterston - kinking of RPA from malpositioned opening
· Central - hard to regulate flow
· Left or right thoracotomy
· Encircle PA just above commissures
· Reduce PA pressure 1/3 systemic
· Trusler's rule for circumference of band
a) Simple defect = 20 mm + wt (kg)
b) Mixing defect = 24 mm + wt (kg)
· Unbalanced AV canal
· Multiple VSD's
· VSD and coarctation
· Single ventricle with increased pulmonary blood flow
· Contraindications to CP bypass
· Late presentation of TGA (with shunt)
· Mortality = 5-20%
· Interval mortality variable
· PA distortion: a low band results in supravalvular PS, a distal band can disrupt the pulmonary bifurcation
· Subaortic obstruction in single ventricle = 30-40%; hypertrophy behind the band may obstruct interventricular connections
· Original experimental shunt failed to produce pulmonary hypertension
· Blue baby operation, 1945
· Left or right on opposite side of aortic arch
· Subclavian artery to PA anastomosis is technically challenging
· PA distortion
· Left or right on the same side of aortic arch
· 4 mm or 5 mm PTFE
· Subclavian orifice acts as regulator
· More reproducible
· Less PA distortion
· Better PA growth
· Blalock-Hanlon septectomy - closed procedure
· Rashkind balloon septostomy - 90% effective
· Park - blade septostomy at catheterization
· Open atrial septectomy - concomitant procedure
1) Bidirectional Glenn
· SVC to PA (end-to-side)
· Reduced ventricular work
· Reduces Fontan mortality
· Flow goes to both lungs, so subsequent Fontan procedure will use both lungs
2) Classical Glenn
· SVC to RPA (end-to-end)
· Divides pulmonary circulation
· Late arterio-venous fistula
· Diverts all venous return to the larger right lung, so subsequent Fontan procedure can only use the smaller left lung