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Computed tomography angiography successfully used to diagnose postoperative systemic-pulmonary artery shunt narrowing.

Piggott KD, Nykanen DG, Smith S - Case Rep Cardiol (2011)

Bottom Line: In recent years, there has been a marked reduction in surgical mortality for many complex forms of congenital heart disease.Many diagnostic modalities are available to aide in diagnosis of postoperative shunt complications including echocardiography and cardiac catheterization but these may be invasive, inconclusive, or difficult to obtain adequate images.These findings along with clinical suspicion appropriately guided us toward cardiac catheterization.

View Article: PubMed Central - PubMed

Affiliation: Arnold Palmer Hospital for Children, Congenital Heart Institute, Orlando, FL 32806, USA.

ABSTRACT
In recent years, there has been a marked reduction in surgical mortality for many complex forms of congenital heart disease. Treatment or palliative strategies vary but may include systemic-pulmonary central or Blalock-Taussig shunt. These shunts can be complicated by overcirculation, infection, thrombosis, and thromboembolism. Many diagnostic modalities are available to aide in diagnosis of postoperative shunt complications including echocardiography and cardiac catheterization but these may be invasive, inconclusive, or difficult to obtain adequate images. Computed tomography angiography (CTA) has many attributes that make it potentially useful in the evaluation of congenital heart disease and postoperative shunt complications. We report one patient where CTA guided the post-operative algorithm and appropriately identified a shunt narrowing despite repeated echocardiograms showing a patent shunt. These findings along with clinical suspicion appropriately guided us toward cardiac catheterization. To our knowledge, this is the first paper where CTA appropriately suspected a shunt narrowing in the absence of echocardiographic confirmation.

No MeSH data available.


Related in: MedlinePlus

CT angiography with 3-dimensional reconstruction demonstrating a narrowing of the modified BT shunt at the point of anastamosis with the pulmonary artery.
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fig2: CT angiography with 3-dimensional reconstruction demonstrating a narrowing of the modified BT shunt at the point of anastamosis with the pulmonary artery.

Mentions: A 2-month-old female with tricuspid atresia, intact ventricular septum, absent pulmonary valve, and aneurysmal right ventricle. The subject of this paper is a 2 month old female. On day 4 of life, she underwent surgical palliation including placement of a 3.5 millimeter modified Blalock-Taussig shunt with transection and oversewing of the main pulmonary artery. Her initial postoperative course was uneventful. She had a normal blood pressure, normal heart rate, an audible shunt murmur, and oxygen saturation in room air of 75–85%. Mechanical ventilation was weaned, and on postoperative day 5 she was extubated. She failed extubation immediately requiring reintubation secondary to extrathoracic airway obstruction. The patient's ventilator was weaned a second time over a 5-day period. During this time period, she had 3 episodes of hypoxia requiring upward titration of ventilator settings. 2 of the episodes were transient and self-resolving. Chest radiographs were unremarkable and echocardiogram on both occasions showed shunt flow with no identified area of stenosis. On postoperative day 9 she had an episode of persistent hypoxia (oxygen saturation 50–60%) for 2 hours. A shunt murmur was noted, however, slightly diminished. The patient was started on a heparin infusion for presumed shunt thrombosis, and an echocardiogram was performed. Echocardiogram at that time showed adequate shunt flow and did not identify an area of narrowing. Repeated attempts to wean mechanical ventilation resulted in respiratory distress. On postoperative day 13, a computed tomography angiogram was performed which showed a stenosis of the shunt at the anastamosis of the right pulmonary artery (Figures 1 and 2). At cardiac catheterization, stenosis was confirmed and treated with stent implantation (Figures 3(a) and 3(b)). Over the next 2 days, her ventilator was weaned and she was extubated without complication.


Computed tomography angiography successfully used to diagnose postoperative systemic-pulmonary artery shunt narrowing.

Piggott KD, Nykanen DG, Smith S - Case Rep Cardiol (2011)

CT angiography with 3-dimensional reconstruction demonstrating a narrowing of the modified BT shunt at the point of anastamosis with the pulmonary artery.
© Copyright Policy - open-access
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC4008088&req=5

fig2: CT angiography with 3-dimensional reconstruction demonstrating a narrowing of the modified BT shunt at the point of anastamosis with the pulmonary artery.
Mentions: A 2-month-old female with tricuspid atresia, intact ventricular septum, absent pulmonary valve, and aneurysmal right ventricle. The subject of this paper is a 2 month old female. On day 4 of life, she underwent surgical palliation including placement of a 3.5 millimeter modified Blalock-Taussig shunt with transection and oversewing of the main pulmonary artery. Her initial postoperative course was uneventful. She had a normal blood pressure, normal heart rate, an audible shunt murmur, and oxygen saturation in room air of 75–85%. Mechanical ventilation was weaned, and on postoperative day 5 she was extubated. She failed extubation immediately requiring reintubation secondary to extrathoracic airway obstruction. The patient's ventilator was weaned a second time over a 5-day period. During this time period, she had 3 episodes of hypoxia requiring upward titration of ventilator settings. 2 of the episodes were transient and self-resolving. Chest radiographs were unremarkable and echocardiogram on both occasions showed shunt flow with no identified area of stenosis. On postoperative day 9 she had an episode of persistent hypoxia (oxygen saturation 50–60%) for 2 hours. A shunt murmur was noted, however, slightly diminished. The patient was started on a heparin infusion for presumed shunt thrombosis, and an echocardiogram was performed. Echocardiogram at that time showed adequate shunt flow and did not identify an area of narrowing. Repeated attempts to wean mechanical ventilation resulted in respiratory distress. On postoperative day 13, a computed tomography angiogram was performed which showed a stenosis of the shunt at the anastamosis of the right pulmonary artery (Figures 1 and 2). At cardiac catheterization, stenosis was confirmed and treated with stent implantation (Figures 3(a) and 3(b)). Over the next 2 days, her ventilator was weaned and she was extubated without complication.

Bottom Line: In recent years, there has been a marked reduction in surgical mortality for many complex forms of congenital heart disease.Many diagnostic modalities are available to aide in diagnosis of postoperative shunt complications including echocardiography and cardiac catheterization but these may be invasive, inconclusive, or difficult to obtain adequate images.These findings along with clinical suspicion appropriately guided us toward cardiac catheterization.

View Article: PubMed Central - PubMed

Affiliation: Arnold Palmer Hospital for Children, Congenital Heart Institute, Orlando, FL 32806, USA.

ABSTRACT
In recent years, there has been a marked reduction in surgical mortality for many complex forms of congenital heart disease. Treatment or palliative strategies vary but may include systemic-pulmonary central or Blalock-Taussig shunt. These shunts can be complicated by overcirculation, infection, thrombosis, and thromboembolism. Many diagnostic modalities are available to aide in diagnosis of postoperative shunt complications including echocardiography and cardiac catheterization but these may be invasive, inconclusive, or difficult to obtain adequate images. Computed tomography angiography (CTA) has many attributes that make it potentially useful in the evaluation of congenital heart disease and postoperative shunt complications. We report one patient where CTA guided the post-operative algorithm and appropriately identified a shunt narrowing despite repeated echocardiograms showing a patent shunt. These findings along with clinical suspicion appropriately guided us toward cardiac catheterization. To our knowledge, this is the first paper where CTA appropriately suspected a shunt narrowing in the absence of echocardiographic confirmation.

No MeSH data available.


Related in: MedlinePlus