Right Modified Blalock-Taussig-Thomas Shunt With a Cryopreserved Saphenous Vein in a DORV With Criss-Cross Heart and Severe RVOT

The authors present a right modified Blalock-Taussig-Thomas shunt via median sternotomy using a cryopreserved saphenous vein homograft. The patient was a 2-month-old, 5.2 kg infant with heterotaxy, situs ambiguous, and dextrocardia. He presented with cyanosis and an echocardiogram showed double outlet right ventricle with transposed great arteries and multilevel severe right ventricular outflow tract obstruction. He had a suboartic ventricular septal defect, so a Tetralogy of Fallot-like physiology. His left ventricle was small to allow for a safe one-stage two-ventricle repair.

Due to his repeat cyanotic spells, he was admitted with a plan of providing an additional source of pulmonary blood flow via a systemic-to-pulmonary artery shunt. Through a median sternotomy, and after pericardiotomy and thymectomy, the left innominate vein was dissected and isolated with a vessel loop to expose the innominate artery. The innominate artery was dissected and isolated so as the right main branch pulmonary artery.

Systemic heparin was administered at 100 units/kg. The proximal anastomosis between the cryopreserved saphenous vein homograft (5-6 mm) and the innominate artery was constructed using running 7/0 prolene sutures. The right-sided ductus arteriosus was then divided, followed by construction of the distal anastomosis of the vein graft to the right pulmonary artery using running 8/0 prolene sutures.

The authors used a slightly larger graft size for this patient to provide additional volume overload to the left ventricle, which may help future growth. Hemostasis was then achieved, followed by chest drain placement and incision closure in the standard fashion. He was extubated in the operating room and oxygen saturation on room air was about 85%.

The postoperative course was uncomplicated, and he was dismissed on the eighth postoperative day with oxygen saturation monitor. The plan will be to assess his left ventricle size in the follow-up period with the goal of two-ventricle repair.

References

1. Rao, PS, Vidyasagar, D. Principles of management of the neonate with congenital heart disease. In Perinatal Cardiology: A Multidisciplinary Approach. Cardiotext Publishing: Minneapolis, MN: Cardiotext Publishing; 2015.
2. Kaur R, Bhurtel D, Bielefeld MR, Morales JM, Durham LA 3^rd. Cryopreserved saphenous vein compared with PTFE graft for use as modified Blalock-Taussig or central shunt in cyanotic congenital heart disease. World J Pediatr Congenit Heart Surg. 2018 Sep;9(5):509–512.
3. Kilic A, Cameron DE, Vricella LA. Use of cryopreserved saphenous vein grafts in congenital heart surgery. J Thorac Cardiovasc Surg. 2012 Dec;144(6):1520-1522.

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