Author + information
- Published online September 4, 2017.
- Emile Bacha, MD∗ ()
- Department of Surgery, Division of Cardiac, Thoracic and Vascular Surgery, Columbia University/New York-Presbyterian/Morgan Stanley Children’s Hospital, New York, New York
- ↵∗Address for correspondence:
Dr. Emile Bacha, Department of Surgery, Division of Cardiac, Thoracic and Vascular Surgery, Columbia University/New York-Presbyterian/Morgan Stanley Children's Hospital, Room 274, 3959 Broadway, New York, New York 10032.
Changes in medicine occur incrementally rather than in one big paradigm change. A huge paradigm change occurred on November 22, 1944, with the introduction of aortopulmonary shunts by Drs. Blalock and Taussig, initially as a turn down and anastomosis of the subclavian artery to the pulmonary artery (the so-called “classic” Blalock-Taussig shunt) on a 15-month-old child. That event ushered the era of modern congenital heart surgery, adding years and sometimes decades to these poor children’s lives. Then, in the pre-prostaglandin era, emergency shunts were crucial in maintaining pulmonary blood flow and thus survival. In recent years, shunt use has steadily decreased due to increased primary 1-stage repairs of lesions such as tetralogy of Fallot and the popularity of the Norwood/Sano (right ventricle–pulmonary artery conduit) operation. The shunts’ inherent morbidity and mortality, in the vicinity of 20% and 10%, respectively, are considerable. Shunts belong in the STAT (Society of Thoracic Surgeons–European Association for Cardio-Thoracic Surgery Congenital Heart Surgery Mortality) category 4 (5 being the highest), and acute shunt thrombosis is the most dreaded complication. A shunt (which is typically a Gore-Tex tube [Gore-Tex, W.L. Gore & Associates, Newark, Delaware]) is an imperfect operation that essentially presents 3 interrelated problems: 1) the technical art of performing a shunt (risk of kinking, stenosis, nonlaminar flow); 2) the risk of thrombosis, even with a perfectly well-constructed shunt, due to the interface between the artificial surface and the blood; and 3) delivery of pulmonary blood flow that is continuous throughout the cardiac cycle with possible coronary flow impairment and inadequate (too much or too little) and difficult-to-manage pulmonary blood flow. Because some congenital heart malformations, such as specific single ventricles such as tricuspid atresia or some types of pulmonary atresia, still require a shunt, any improvement in shunt management is welcome. In this issue of JACC: Cardiovascular Interventions, this is what Ligon et al. (1) has achieved here: an incremental improvement in the management of shunt complications. For these typically very sick patients who are often supported on extracorporeal membrane oxygenation, a trip back to the operating room is not advisable. Catheter-based interventions are much more preferable. The femoral vessels have traditionally been the route of access. If the carotid artery was used at all, it was via a surgical cutdown. The novelty of this series is that the carotid was approached percutaneously with great success. This was initially done in cases where the femoral approach failed, and then increasingly as a first-line approach. It seems to me this should become the standard approach in these situations.
↵∗ Editorials published in JACC: Cardiovascular Interventions reflect the views of the authors and do not necessarily represent the views of JACC: Cardiovascular Interventions or the American College of Cardiology.
Dr. Bacha has reported that he has no relationships relevant to the contents of this paper to disclose.
- 2017 American College of Cardiology Foundation