Correspondence

Spontaneous Expectoration of a Prosthetic Graft Nine Years after a Blalock-Taussig Shunt Procedure

N Engl J Med 1993; 329:1899December 16, 1993

Article

To the Editor:

The modified Blalock-Taussig operation, now performed by inserting a polytetrafluoroethylene graft between the subclavian and pulmonary arteries, is considered to be the palliative procedure of choice in infants with cyanosis who are less than three months of age. The operation is associated with a low mortality rate, excellent patency, and a low rate of long-term complications1,2.

We report on a child born with cyanosis in 1983 who had a congenitally corrected L-transposition of the great arteries with a large ventricular septal defect, pulmonary atresia, and a cleft mitral valve with moderate regurgitation. In the first week after birth, a modified shunt was established between the subclavian and pulmonary arteries with a 5-mm Gore-Tex graft inserted through a right posterior thoracotomy. Because of stenosis at the pulmonary anastomosis and occlusion of the shunt, another shunt was established six months later on the left side with a 6-mm Gore-Tex graft. Postoperative recovery was uneventful, and several subsequent echocardiographic examinations demonstrated the patency of the shunt.

In 1987 chest radiography and hilar tomography showed chronic bronchitis and a partial collapse of the right lung. Compression of the carina was suspected, but the right main bronchus was not visualized. The child's condition was stable with a slight increase in polycythemia. Neither a Fontan repair nor a vena cava-pulmonary anastomosis was undertaken, because of persistently hypoplastic peripheral lung arteries, pulmonary hypertension, and severely elevated pulmonary vascular resistance.

In December 1992, nine years after surgery, the child expectorated a cylindrical object that was 4 cm by 5 cm and corresponded exactly to the previously implanted Gore-Tex graft. The mother brought the foreign body to the next cardiologic consultation. No bleeding or clinical or hematologic signs of infection were present. Chest radiography showed a normal cardiopulmonary site, and the pulses were normal in both arms. The child's general condition remains stable but with severe cyanosis.

The principal disadvantage of a modified Blalock-Taussig shunt is the use of artificial material that does not enlarge as the child grows3. The most common complications of shunts are thrombosis, anastomotic stenosis, pulmonary-artery distortion, persistent leakage of a plasmalike fluid through the prosthesis, and infection.

The unusual self-resolving complication in our patient is similar to that in another reported patient in whom the prosthesis led to nonresolving pneumonia. After eroding the bronchial tree, that prosthesis was removed by bronchoscopy4. Our report demonstrates that a vascular prosthesis can be rejected without serious bleeding or ischemic or infectious complications.

T. Carrel, M.D.
H. Winklehner, M.D.
M. Pasic, M.D.
M. Turina, M.D.
University Hospital, CH-8091 Zurich, Switzerland

4 References

1. 1

   Bove EL, Kohman L, Sereika S, et al. The modified Blalock-Taussig shunt: analysis of adequacy and duration of palliation. Circulation 1987;76:Suppl III:III-19
   

2. 2

   Lamberti JJ, Carlisle J, Waldman JD, et al. Systemic-pulmonary shunts in infants and children: early and late results. J Thorac Cardiovasc Surg 1984;88:76-81
   Web of Science | Medline

3. 3

   Woolf PK, Stephenson LW, Meijboom E, et al. A comparison of Blalock-Taussig, Waterston, and polytetrafluoroethylene shunts in children less than two weeks of age. Ann Thorac Surg 1984;38:26-30
   CrossRef | Web of Science | Medline

4. 4

   Lodge JP, Hamilton JR, Saunders NR, Walker DR. Right lower lobe consolidation: an unusual complication of the modified Blalock-Taussig operation. Ann Thorac Surg 1987;44:201-202
   CrossRef | Web of Science | Medline

Citing Articles (3)

Citing Articles

1. 1

   Nisreen Rumman, Stuart Berger, Aparna Rao. (2011) Hemoptysis in a Teenager with Congenital Heart Disease. Pediatric Cardiology 32:1, 105-107
   CrossRef

2. 2

   Shi-Min Yuan, Amihay Shinfeld, Ehud Raanani. (2009) The Blalock-Taussig Shunt. Journal of Cardiac Surgery 24:2, 101-108
   CrossRef

3. 3

   Joseph J Amato, William I Douglas, George J Aboo Eid, Frederick Lukash. (2000) Removal of an infected ventricular septal defect patch after tetralogy repair. The Annals of Thoracic Surgery 70:6, 2140-2142
   CrossRef