Novel Perioperative Strategy For The First Blalock-taussig Shunt In Infants With PDA Dependent Circulation
Sadahiro Sai, Satoshi Matsuo, Shingo Takahara, Naoki Masaki, Koh Sakatsume, Akinobu Konishi
Miyagi Children'S Hospital, Sendai, Japan
Objectives Modified Blalock-Taussig shunt as(mBTS) for pulmonary atresia(PA) or critical pulmonary stenosis(PS) patients which depend on patent ductus arteriosus(PDA) has still had non-negligible mortality and morbidity because of postoperative imbalance between pulmonary and systemic circulation. We have pursued the validity of our strategy for perioperative management of mBTS. Methods Our first strategy was reducing dose or discontinuation of Lipo-prostaglandin E1 a week before surgery(op.) followed by inhalation of nitrogen if necessary, and targeting SpO2 70-80% to avoid cardiac failure by reducing preload (low pulmonary blood flow strategy). The second one was administration of PDEIII inhibitor from anesthetic induction to stabilize Qp/Qs by reducing afterload(low vascular resistance strategy). From July 2008 to July 2016, 43 pulmonary atresia and critical PS infants (PA 35, PS 8) underwent the first mBTS through median approach using no cardiopulmonary bypass were divided into two groups: Group C; conventional management (n=20), Group S; new strategy (n=23). Median age and body weight were 38 days (range 11 to 70) and 3.4kg (range 2.4 to 4.0). The primary endpoint was postoperative excessive or low pulmonary flow event such as cardiopulmonary resuscitation, PDA ligation, shunt clipping and ECMO installation. The secondary outcomes were preoperative change of SpO2 and BNP level, postoperative peak lactate and catecholamine index(CI) in each group. Results There were one death and six postoperative excessive pulmonary flow events (30%) in Group C but no event in Group S. Preoperative SpO2 and BNP level were reduced during a week respectively. (88.0+/-3.2% at 1 week before op. and 79.8+/-5.0 % at op. in SpO2, 476+/-190 pg/ml at 1week before op. and 173+/-146 pg/ml at op. in BNP level). Preoperative SpO2 at op. was 86.3+/-7.1% in group C (vs. group S, p< 0.01). Preoperative BNP level at op.was 344+/-617 in group C (vs. group S, p= 0.31). There were significant difference in postoperative CI and max lactate level between C and S group (CI 14.2+/-1.4, max lactate 6.1+/-7.6 mmol/L in group C); CI 8.0+/-1.5(p<0.01), max lactate 2.7+/-1.1 mmol/L(p<0.05) in group S) Conclusions These strategies could contribute to carry low postoperative mortality and morbidity of the first mBTS in PA or critical PS infants with PDA dependent circulation who may suffer deleterious events in perioperative period.
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