J THORAC CARDIOV ASC SURG 79: 194-20 1, 1980

The changing role of palliative procedures In

the treatment of infants with congenital
heart disease
The use of palliative procedures in the treatment of infants with congenital heart disease has been an
established and accepted form of therapy. With progression toward more corrective operations in the first
year of life, the more recent use of palliative procedures is examined. Five hundred two infants underwent
cardiac operation in the first year of life at the University of California, San Francisco, during the period
from Jan. 1, 1975, through June I, 1979. Four hundred twenty-three (84.3%) underwent "corrective"
procedures. One hundred forty-seven of them had tetraology of Fallot, ventricular septal defect (VSD),
transposition of the great arteries (TGA), and truncus arteriosus types 1 and 11. These patients, commonly
treated in the past with conventional means of palliation, underwent either' 'correction" or an outflow
patch procedure. The operative survival rate was 91%. During the same period, only 26 (5.2%)
conventional palliative procedures were performed. Pulmonary artery banding was performed in 13,
closed atrial septectomy in two, Blalock-Taussig shunt in five, and Waterston shunt in six. An additional
53 (10.4%) unconventional palliations were performed. Lesions palliated by conventional or
unconventional procedures included the complex malformations of pulmonary, tricuspid, and mitral
atresia, single ventricle, endocardial cushion defect, TGA with VSD, Taussig-Bing deformity, and
Ebstein's anomaly. These data demonstrate the changing role for the palliative procedure in the treatment
of infants with congenital heart disease. Selection of the proper palliative procedure for the complex
lesions not amenable to early correction should be predicated on both the nature of the lesion and the
factors which influence the ultimate surgical repair, the most important of which is induction of
symmetrical growth and development.

Kevin Turley, M.D., William Y. Tucker, M.D., and Paul A. Ebert, M.D.,
San Francisco, Calif.

Conventional palliative procedures in the form of
pulmonary artery banding, closed atrial septectomy,
and peripheral shunts have formed the standard by
which survival in infants with congenital heart disease
has been judged. They were necessitated by inability to
produce more physiological palliation (' 'correction")
in early infancy without an extremely high operative
mortality rate.
Recently, the role of conventional palliative proce-
dures has changed markedly. Survival is now possible
with many types of "correction, " central shunting, and
other unconventional forms of central palliation which
result in a more physiological type of palliation. Such
From the University of California, San Francisco, Department of
Surgery, San Francisco, Calif. 94143.
Read at the Fifth Annual Meeting of The Samson Thoracic Surgical
Society, Sun Valley, Idaho, June 5 to 8, 1979.
Address for reprints: Kevin Turley, M.D., Department of Surgery,
University of California, San Francisco, California 94143.
194 0022-5223/80/020194+08$00.80/0 © 1980 The C. V. Mosby Co.
procedures can be accomplished in early infancy with
acceptable risk. The magnitude of this change and its
effect on both the use and selection of operative proce-
dures in early infancy are examined.
Patients and methods
During the period from Jan. 1, 1975, through June 1,
1979, 502 patients in the first year of life underwent
operative procedures on the Cardiothoracic Surgery
Service at the University of California, San Francisco,
California. The age distribution is noted in Fig. 1.
These patients can be divided into four groups (Table
I). Group 1 includes those in whom no palliative proce-
dure is possible, and thus correction in infancy is nec-
essary. Group 2 includes patients with four lesions
commonly palliated in the past, in which efficacy of
such conventional palliation has been judged; in this
group correction in early infancy has recently become
common. Group 3 includes patients in whom either
 Volume 79
Number 2 Palliation of congenital heart disease 195
February, 1980

Table I. Congenital heart disease 300

Group I Lesions 260

Pump 0
Non-pump ~
Group I Aortic stenosis, pulmonary stenosis, mitral stenosis, 220
total anomalous pulmonary venous connection, cor C-Correction

triatriatum, coarctation, interrupted arch, patent duc-

'"
I-
z P·Paliiation
w 180
tus arteriosus i=
Group 2 Tetralogy of Fallot, transposition of the great arteries
«
Q..
140
(simple), ventricular septal defect, truncus arteriosus 0
types I and II Z
100
Group 3 Transposition of the great arteries with ventricular septal
defect, pulmonary atresia, endocardial cushion defect, 60
truncus arteriosus types III and IV
Group 4 Single ventricle, double-outlet right or left ventricle,
Ebstein's anomaly, tricuspid atresia, mitral atresia,
20
c P c pCP
CL
c P
hypoplastic right or left ventricle
0-3 4-6 7-9 10-12
AGE IN MONTHS
Table II. Modes of therapy Fig. 1. Age distribution with type of cardiopulmonary sup-
Palliation port and type of procedure. Included are 502 infants, treated
in the first year of life, between Jan. I, 1975, and June I,
"Correction' ,
Con-
ventional
I Uncon-
ventional Totals
1979.

in only 26 (5.2%) of the patients; an additional

CPB 271 I 36
Non-CPB 152
25 17
Totals 423 (84.3%) 26 (5.1%) 53 (10.6%)
Legend: CPB, Cardiopulmonary bypass.
Table III. "Corrective" operations in Group 2
infants in the first year of life
Lesion
Tetralogy of Fallot
Ventricular septal defect
Transposition of the great arteries
Truncus arteriosus types I and II
Total
*Twelve of the 37 patients with tetralogy of Fallot underwent unconven-
tional palliative procedures.
tOne patient underwent a Blalock-Hanlon septectomy at the age of 2 days. A
"corrective" operation (intra-atrial baffle procedure) was performed at the age
of 8 months.
correction or palliation may be indicated depending on
the anatomy of the lesion and the need for further
growth before correction can be performed. Finally,
Group 4 includes patients with lesions for which no
corrective procedure is usually available in infancy and
only with a palliative procedure producing symmetrical
growth of the pulmonary arteries and cardiac chambers
may any correction be possible at a later date.
Cardiopulmonary bypass was utilized in 308 patients
(61% of the total group) and nonbypass techniques
in 194 (38%). "Correction" was accomplished in 423
(84.3%) of the patients and conventional palliation,
308 (61%)
53 (10.6%) underwent unconventional palliative ap-
194 (38%)
proaches. Table II illustrates these relationships.
502 One hundred forty-seven of the 308 patients treated
with cardiopulmonary bypass technique had Group 2
lesions. These included 37 with tetralogy of FaIlot, 50
with transposition of the great arteries (TGA), 31 with
ventricular septal defects (VSD), and 29 with truncus
arteriosus types I and II. All of these patients were
No.
severely symptomatic, requiring operative intervention
25 (12*) in early infancy. The approach to these four lesions
31 (Group 2) is described in Table III. Of note, only one
50t conventional palliative procedure was performed in this
29
group.
135 During this same period only 26 conventional pal-
liative procedures were performed: pulmonary artery
banding in 13 patients, closed atrial septectomy in
two, and shunting procedures in the form of Blalock-
Taussig anastomoses in five and Waterston shunts in
six (Table IV).
Unconventional procedures for palliation were per-
formed in 53 patients. These include open pulmonary
artery outflow tract patching in 12 of the patients with
tetralogy of Fallot and nine patients with pulmonary
atresia, pulmonary arterial conduit for palliation in one
patient with pulmonary atresia, main aorta-pulmonary
shunts in 10 patients, combined open septectomy and
pulmonary artery bandings in four, and intra-atrial
baffle procedures combined with pulmonary artery
banding in four, In addition, 13 infants underwent for-
malin injections of the ductus arteriosus early in this
series; however, because of the short-term effective-
 The Journal of
196 Turley, Tucker, Ebert Thoracic and Cardiovascular
Surgery

Table IV. Conventional palliative procedures Table VI. Results of "correction" /unconventional
Procedure '-N-O.-o-if-c-a-se-s- palliation in Group 2 infants
Percent
Pulmonary artery banding 13 Lesion survival
Closed atrial septectomy 2
TGA and VSD* Tetralogy of Fallot 37 33 90
TGAt Ventricular septal defect 31 28 90
Blalock-Taussig shunt 5 Transposition of the great arteries 50 50 100
Pulmonary atresia 2 Truncus arteriosus types I and" 29 23 79
Pulmonary atresia with single ventricle I
Pulmonary atresia with TGA I Totals 147 134 91
Pulmonary atresia, tricuspid atresia, and hypo- I
plastic right ventricle
Waterston shunt 6
Table VD. Deaths in Group 2 patients
Pulmonary atresia 4
Pulmonary atresia and mitral stenosis I Lesion Complicating factors
Pulmonary atresia, tricuspid atresia, and hypo- I
plastic right ventricle Tetralogy of 7 mo 7 Outflow patch rupture
Fallot 6 mo 21 PA: Ao ratio 0.25, NEC,
Legend: TGA, Transposition of the great arteries. VSD, Ventricular septal
defect. postop. pulm. hemorrhage,
*Closed atrial septectomy combined with pulmonary artery banding. terratoma
tOne Group 2 patient. 5 mo 2 PA:Ao ratio 0.27, rneningo-
myelocele
(OTP) 6 mo 4 Illeal atresia, preop. seizures
Table V. Palliated lesions Ventricular 14 days OR Severe CHF, on respirator
septal from birth
No. of defect 25 days OR Severe CHF, on respirator
Lesions patients from birth
45 days 8 Gastroschisis, severe CHF
Pulmonary atresia 37
Tricuspid atre- 106 days I PVOD, R,,:Rs 0.48, Q,,:Qs
Ebstein's anomaly I
sia types I 1.5: I
Hypoplastic left ventricle I
and " 40 days Truncal valve incompetence
Tricuspid atresia 7
requiri ng replacement
Mitral atresia 5
14 days Severe CHF, on respirator
Endocardial cushion defect 4
from birth, weight 2,580
Single ventricle 2
gm
TGA with single ventricle 4
5 days OR Preop. arrest, PVOD; at au-
TGA with VSD 3
topsy, marked medial hy-
Corrected TGA I
pertrophy of pulm. vessels
Previous Taussig-Bing shunt I
137 days 2 PVOD; at autopsy, marked
Total 66 medial hypertrophy of
pulm. vessels
Legend: TGA, Transposition of the great arteries. VSD, Ventricular septal
20 days OR PVOD; at autopsy, marked
defect.
medial hypertrophy of
pulm. vessels
ness of this procedure, it rarely is used currently.
Legend: PA:Ao, Pulmonary artery to aorta (anteroposterior projection-
The 66 complex lesions (Groups 3 and 4) in which right PA-Ao diameter). NEC, Necrotizing enterocolitis. CHF, Congestive
palliative procedures were used are described in heart failure. OTP. Outflow tract patch. OR. Operating room. PVOD, Pul-
monary vascular obstructive disease. RI':R s, Ratio of pulmonary to systemic
Table V; the diversity and complex nature of these resistance. Qp:Qs. Ratio of pulmonary to systemic flow.
lesions can be appreciated.
survival. Overall, the operative survival rate was 91%.
Results These results are described in Table VI. Only a single
One hundred forty-seven patients underwent "cor- patient with a Group 2 lesion underwent a conventional
rection " or unconventional palliation for the four le- palliative procedure during this period. This patient,
sions once commonly palliated in early infancy, This who had TGA, subsequently required correction in the
group included 37 patients with tetralogy of Fallot, form of an intra-atrial baffle procedure in the first year
with a 90% survival; 31 patients with VSDs, 90% sur- of life. Twelve patients in this group with tetralogy of
vival; 50 patients with TGA, 100% survival; and 29 Fallot underwent unconventional palliative operations
patients with truncus arteriosus types I and II, 79% in the form of outflow tract patches, as described by
Volume 79
Number 2 Palliation of congenital heart disease I 97
February, 1980

Table VIII. Palliative procedures

Conventional" Unconventional"

Lesion PAB I B-H I B-T IWat, RVOTP

IA-P shunt
IConduit
IOpen sept.j Baffie
and banding and banding
IDuctal
injection

Pulmonary atresia 2 (0) 4 (1) 9 (3) 1 (1) 1 (0) 8 (0)

Pulmonary atresia, single ventricle 1 (0) 2 (1) 2 (0)
Pulmonary atresia, TGA, single ven- 1 (0) 2 (0)
tricle
Pulmonary atresia, mitral stenosis 1 (0)
Pulmonary and tricuspid atresia, hypo- 1 (0) 1 (0) 1 (0)
plastic right ventricle
Endocardial cushion defect 4 (1)
Single ventricle 2 (0)
Tricuspid atresia 5 (2) 2 (1)
Mitral atresia 4 (1) I (1)
TGA, VSD 2 (1) 1(0)
TGA, single ventricle 1 (0) 3 (0)
Corrected TGA 1 (1)
Hypoplastic left ventricle I (0)
Taussig-Bing I (0)
Ebstein's anomaly 1(0)
[TGA]t I (0)
[Tetralogy of Fallot]'t 12 (1)
Totals 13 (3) 2 (0) 5 (0) 6 (1) 21 (4) 10 (4) 1(0) 4 (2) 4 (1) 13 (0)

Legend: PAB, Pulmonary artery band. B-H, Blalock-Hanlon septectomy. B-T, Blalock-Taussig shunt.Wat. Waterston shunt. RVOTP, Right ventricular outflow
tract patch. A-P, Aorta-Pulmonary shunt. TGA, Transposition of the great arteries. VSD, Ventricular septal defect.
"Figures in parentheses indicate deaths.
tBrackets indicate Group 2 lesions.

Tucker and associates, t and will require subsequent
VSD closure.
The 13 deaths are reviewed in Table VI. Improved
survival through the use of a two-stage approach may
have been possible in the two patients with tetralogy of
Fallot with right pulmonary artery-ascending aortic
ratios below 0.3 (diameter in anterior projection'). In
these two, right ventricular outflow tract patches with-
out VSD closure might have resulted in survival. A
technical problem that occurred in one patient with te-
tralogy of Fallot, outflow patch disruption, might have
been avoidable had a shunt been used. The severity of
the congestive failure present in the three infants with
VSDs necessitated their operations in early infancy.
Two of the three had received respirator support from
birth. Pulmonary vascular obstructive disease was pre-
sent in four of the six patients with truncus arteriosus
who died. Finally, one patient had trucus valvular in-
competence, and four of the six patients were 2 months
old or younger, so that the ventricular reconstructi ve
operation was more difficult. These deaths are noted in
Table VII. None of these latter patients were better
candidates for a two-stage approach.
Sixty-six patients, all with Group 3 or 4 lesions,
underwent either conventional (25) or unconventional
(41) palliative procedures during the same period
(excluding the 12 patients subjected to outflow tract
patching who had tetralogy of Fallot and the single
patient with TGA and a Blalock-Hanlon anastomosis).
The majority of these patients (37) had variants of pul-
monary atresia, including pulmonary atresia with single
ventricle, pulmonary atresia with TGA, pulmonary at-
resia with mitral stenosis, and pulmonary atresia with
tricuspid atresia and hypoplastic right ventricle. The
operative survival rate was 76%. Four patients had se-
vere endocardial cushion defects (75% survival); two
patients had single ventricle (100% survival) ; seven
patients had tricuspid atresia (57% survival); five pa-
tients had mitral atresia (60% survival); four patients
had TGA and single ventricle (100% survival); and
three patients had TGA with large VSD (67% survi-
val). A single patient with corrected TGA failed to
survive, and one patient with Ebsteins anomaly, one
with hypoplastic left ventricle, and one with Taussig-
Bing anomaly had successful palliation. Overall survi-
val for the palliated group was 74%. The operative
approaches and results (both conventional and uncon-
ventional) in the complex Group 3 and 4 lesions in
which palliation was employed are summarized in
Table VIII.

198 Turley, Tucker. Ebert
Results of this series demonstrate the change in the
use of palliative procedures which occurs when an early
corrective approach is employed. They demonstrate
that correction or central palliation of Group 2 lesions
can be performed with acceptable survival (Table VI).
When such an approach was employed, the need for pal-
liative procedures was confined to certain Group 3 pa-
tients who were poor candidates for early correction, in
whom a better two-stage result was anticipated, and
also to those Group 4 patients in whom no early correct-
ive procedure was currently available. Selection of the
mode of palliation of these patients was based on the
goal of maximal long-term palliation and symmetrical
growth, and a central palliative approach was employed
whenever possible. Comparable survival rates are
noted in the complex lesions treated by both these un-
conventional palliative procedures and the few conven-
tional procedures performed, further supporting their
use (Table VIII).
Discussion
Treatment of infants in the first year of life with
congenital heart disease until recently has depended
upon conventional palliative procedures in the form of
pulmonary artery bands, closed atrial septectomy, and
pulmonary-systemic shunt procedures (Blalock-Taus-
sig, Waterston, Potts, and Glenn). These procedures
are designed, to allow survival in the infant groups so
that correction may be accomplished at an older age.
With the exception of those lesions for which no pallia-
tion is applicable (Group I), this two-stage approach
has been commonly applied.
Conventional palliative procedures are designed to
alter the hemodynamic effects which result in infant
death. These include increased pulmonary blood flow
with subsequent development of pulmonary vascular
obstructive disease or progressive congestive heart
failure, inadequate intracardiac mixing in lesions with
pulmonary and systemic systems in parallel, and in-
adequate pulmonary arterial flow owing to right ven-
tricular outflow obstructive lesions. Although such
conventional palliative procedures have been applied in
all patients in whom palliation is possible (Groups 2, 3,
and 4), in the past their efficacy has been judged by
results in several commonly treated lesions, namely
tetralogy of Fallot, VSD, TGA, and truncus arteriosus
types I and II.
Primary "correction" of these Group 2 lesions has
recently been reported. The results of "correction" of
tetralogy of Fallot reveal both a lower initial mortality
rate and a lower cumulative mortality rate.t' Like-
wise, treatment of symptomatic VSD and TGA yields
The Journal of
Thoracic and Cardiovascular
Surgery
encouraging results'-" Finally, in patients with truncus
arteriosus types I and II, in whom a greater than 50%
mortality from banding had been commonplace,": 9 a
"corrective" procedure is now available. to
These "corrections," it should be noted, represent
only a more physiological form of palliation. Although
some may result in a nearly normal heart (e.g., VSD),
a persistence of some pathological condition (e.g.,
pulmonary insufficiency in tetralogy of Fallot, and
ventricular reversal in Mustard and Senning procedures
for TGA) or the necessity for subsequent operations
(e.g., conduit replacement in truncus arteriosus) may
be expected. These procedures, however, do allow for
normal growth and development while fulfilling the
goals for which the conventional palliative procedures
were originally designed. Furthermore, the infant sur-
vival rate is high.
The question arises, which lesions now necessitate
palliation and how might this best be accomplished?
Table V lists the types of lesions necessitating pallia-
tion when the "corrective" approach is employed.
These include lesions in which the anatomy in infancy
is inadequate to allow a "corrective" procedure and
further growth is necessary (e.g., pulmonary atresia),
lesions for which both correction and palliation result in
a high mortality rate but later correction yields a more
satisfactory long-term result (e.g., certain types of
TGA with large VSD, certain endocardial cushion de-
fects, and certain types of single ventricles), and those
lesions for which no satisfactory "corrective" ap-
proach is now available and maximal palliation is de-
sired. The selection of the proper mode of palliation
requires attention to these goals and an appreciation of
the limitations as well as the advantages of each ap-
proach.
Pulmonary arterial banding is the only modality cur-
rently available to decrease pulmonary arterial flow in
patients with severe congestive heart failure. Without
banding or "correction, " pulmonary vascular obstruc-
tive disease causes death from progressive congestive
heart failure or else growth retardation occurs. There is
a substantial operative mortality rate both with the
banding procedure itself (in those without simple
VSDs) and when subsequent "correction" is per-
formed.s: 9 The source of these problems lies in the
nature of the procedure itself; an inadequate or overly
constrictive band may be placed, and pulmonary arte-
rial stenosis or aneurysm formation, pulmonary arterial
rupture, or kinking of one of the distal vessels may
result. 6 Thus the operation should be restricted to those
in whom no correction is available or significantly
improved survival results with its use.
Volume 79
Number 2
February, 1980
Fig. 2. Central palliations: A, Outflow tract patch. B, Conduit. C. Polytetrafluoroethylene tube.
Atrial or ventricular septectomy or intra-atrial baffle
procedures can produce intra-atrial mixing in those pa-
tients with parallel systemic and pulmonary systems or
those in whom parallel flow is present (single ventricle)
or atrial outflow is obstructed. The closed atrial septec-
tomy (Blalock-Hanlon) was developed to achieve this
aim without the use of cardiopulmonary bypass. Use of
this approach prior to the development of the balloon
atrial septostomy and infant "corrective" procedures
allowed some salvage and produced acceptable pallia-
tion (in simple transposition) until "correction" could
be accomplished. II With the advent of "correction" in
infancy, its usefulness must be questioned. 12 Those le-
sions which now require mixing procedures (Table V)
are those in which the potential for correction is
limited. Thus a procedure producing maximal mixing
and long-term palliation (i.e., open septectomy or
baffle procedure) appears warranted.
Finally, there remain those lesions, the most com-
mon group, in which pulmonary arterial blood flow is
inadequate and those in which growth of the pulmonary
tree must be stimulated for "correction" to be possible.
Several conventional shunting procedures have been
utilized toward this end. The Blalock-Taussig, Water-
ston, and Potts procedures all produce aorta-pulmonary
continuity with resultant increased flow. However,
each often is a unilateral shunt which ideally (as re-
ported in some patients with tetralogy of Fallor'")
should produce symmetrical growth of the pulmonary
artery system, but more commonly has a high compli-
cation rate when applied to the infant group. This is
true in particular in those Group 3 and 4 lesions in
which such palliations must now be employed. 14, 15
Shunt occlusion, unilateral pulmonary edema, pul-
Palliation of congenital heart disease I 99
monary arterial hypertension, pulmonary vascular ob-
structive disease, kinking of the pulmonary artery, uni-
lateral pulmonary arterial hypoplasia, progressive
stomal stenosis, and stomal growth with congestive
heart failure have been reported.tv 16, 17 Further, dis-
tortion of the pulmonary arterial anatomy and the
necessity for reconstructive procedures for stomal clo-
sure at the time of correction are common, particularly
in patients with Waterston shunts, and their use in
Group 3 and 4 patients yields the poorest results.!"
Central shunts (Fig. 2) in the form of outflow patches,
pulmonary arterial conduits (rarely used except when
the need for pulmonary valve placement exists), or
main aorta-pulmonary arterial communications utiliz-
ing a polytetrafluoroethylene tube provide systemic
flow and symmetrical growth of the pulmonary arterial
system. In the latter, anastomosis size can be restricted
both by cross-sectional area and length of the graft
placed. 19, 20 These methods allow central palliation,
avoid the problems of stomal growth and arterial kink-
ing, and decrease the necessity for subsequent recon-
struction procedures. These central shunts can provide
many of the advantages afforded by •'corrective" pro-
cedures in Group 2 patients until "correction" can be
performed in Group 3 and 4 patients.
Thus the role of palliative procedures and particu-
larly the conventional form of such procedures has
markedly changed. No longer can they be appraised
against survival in infancy alone. No longer do the
good risk (Group 2) patients form the standard by
which their efficacy is judged. Normal growth and de-
velopment, long-term palliation in those in whom no
correction is available, and the quality of the palliative
results when •'correction " is performed form the stan-

200 Turley, Tucker, Ebert
dard by which each procedure should be evaluated in
the treatment of congenital heart disease in infancy.
REFERENCES
Tucker WY, Turley K, Ullyot 01, Ebert PA: Manage-
ment of symptomatic tetralogy of Fallot in the first year of
life. 1 THoRAc CARDIOVASC SURG 78:494-502, 1979
2 Calder AL, Barratt-Boyes BG, Brandt PWT, Neutze 1M:
Postoperative evaluation of patients with tetralogy of Fal-
lot repaired in infancy. 1 THoRAc CARDIOVASC SURG
77:704-720, 1979
3 Daily PO, Stinson EB, Griepp RB, Shumway NE: Tetral-
ogy of Fallot. Choice of surgical procedure. 1 THoRAc
CARDIOVASC SURG 75:338-343, 1978
4 Starr A, Bonchek LI, Sunderland CO: Total correction of
tetralogy of Fallot in infancy. 1 THoRAc CARDIOVASC
S URG 65:45-57, 1973
5 Blackstone EH, Kirklin rw, Bradley EL, DuShane JW,
Applebaum A: Optimal age and results in repair of large
ventricular septal defects. 1 THoRAc CARDIOVASC SURG
72:661-679, 1976
6 Turley K, Ebert PA: Total correction of transposition of
the great arteries. Conduction disturbances in infants less
than three months of age. 1 THoRAc CARDIOVASC SURG
76:312-320, 1978
7 Zavanella A, Subramanian S: Review. Surgery for trans-
position of the great arteries in the first year of life. Ann
Surg 187:143-150, 1978
8 Mahle S, Nicoloff OM, Knight L, Moller lH: Pulmonary
artery banding. Long-term results in 63 patients. Ann
Thorac Surg 27:216-224, 1979
9 Dooley Kl, Parisi-Buckley L, Fyler DC, Nadas AS: Re-
sults of pulmonary arterial banding in infancy. Survey of
5 years' experience in the New England regional infant
cardiac program. Am 1 Cardiol 36:484-488, 1975
10 Ebert PA, Robinson sr, Stanger P, Engle MA: Pulmonary
artery conduits in infants younger than six months of age.
1 THoRAc CARDIOVASC SURG 72:351-356, 1976
II Gutgesell HP, McNamara DG: Transposition of the great
arteries. Results of treatment with early palliation and late
intracardiac repair. Circulation 51 :32-37, 1975
12 Clarkson PM, Barratt-Boyes BG, Neutze 1M, Lowe JB:
Results over a ten-year period of palliation followed by
corrective surgery for complete transposition of the great
arteries. Circulation 45:1251-1258, 1972
13 Gale AW, Arciniegas E, Green EW, Blackstone EH,
Kirklin lW: Growth of the pulmonary anulus and pulmo-
nary arteries after the Blalock-Taussig shunt. J THORAC
CARDIOVASC SURG 77:459-465, 1979
14 Idriss FS, Cavallo CA, Nikaidoh H, Paul MH, Koopot R,
Muster Al: Ascending aorta-right pulmonary artery
shunt. 1 THoRAc CARDIOVASC SURG 71:49-57, 1976
15 Aziz KU, Olley PM, Rowe RD, Trusler GA, Mustard
WT: Survival after systemic to pulmonary arterial shunts
in infants less than 30 days old with obstructive lesions of
the right heart chambers. Am 1 Cardiol 36:79-482, 1975
The Journal of
Thoracic and Cardiovascular
Surgery
16 Greenwood RD, Nadas AS, Rosenthal A, Freed MD,
Bernhard WF, Castenada AR: Ascending aorta-pulmo-
nary artery anastomosis for cyanotic congenital heart dis-
ease. Am Heart 194:14-20, 1977
17 Laks H, Marco 10, Willman VL: The Blalock-Taussig
shunt in the first six months of life. 1 THoRAc CAR-
DIOVASC SURG 70:687-691,1975
18 Lennox SC: Late results of aortopulmonary shunts,
Modern Cardiac Surgery, DB Longmore, ed., Baltimore,
1978, University Park Press, pp 219-221
19 Gazzaniga AB, Lamberti 11, Siewers RD, Sperling DR,
Dietrick WR, Arcilla RA, Replogle RL: Arterial prosthe-
sis of microporous expanded polytetrafluoroethylene for
construction of aorto-pulmonary shunts. 1 THoRAc CAR-
DIOVASC SURG 72:357-363, 1976
20 Miyamoto K, Zavanella C, Lewin AN, Subramanian S:
Aorta-pulmonary artery shunts with expanded polytet-
rafluoroethylene (PTFE) tube. Ann Thorac Surg 27:413-
417, 1979
Discussion
DR. GEORGE G. LINDESMITH
Los Angeles. Calif.
I would like to congratulate Dr. Turley and his colleagues
for truly outstanding results in the surgical management of
infants with cardiovascular disease.
At the Childrens Hospital of Los Angeles, we basically
agree with the concept of performing an intracardiac repair as
an initial procedure when feasible. A brief look at the trends
in our experience with systemic-pulmonary shunts will rein-
force this agreement.
The first slide shows our total experience with systemic-
pulmonary artery shunts, the bulk of which have been
Taussig-Blalock shunts. During the interval from 1946 to
1973, 84% of the patients were over I year of age at the time
of the shunt operation: beyond that time, 62% of the patients
were under I year of age, with 28% of them under I month.
The next slide shows our experience with the Blalock-
Taussig operation for children under I year of age, during the
years surveyed by the authors. This slide simply lists the
diagnoses for which this operation was performed. The diag-
noses were generally those for which there was no intracar-
diac repair readily available for the patient. The majority of
these patients were in the first 2 months of life.
Finally, I would like to comment on some of the concepts
which were touched upon by the authors, hoping that this will
generate a response from Dr. Turley.
Those of us involved in the care of children with congenital
heart disease must be very careful in our use of the terms
"palliative" and "corrective. " Dr. Turley has addressed this
point in the manuscript, but I think further emphasis is war-
ranted. The fact is that relatively few of the lesions which we
treat surgically can be proved as yet to be other than palliated
by the surgical procedures which we perform. This applies in
particular to the diagnosis of TGA and the treatment of trun-
Volume 79
Number 2
February, 1980
cus arteriosus, Tetralogy of Fallot, for that matter, probably
also can be included in this category. I realize that this con-
cern is purely semantic. However, the inappropriate use of
the term "corrective" frequently supplies an incorrect impli-
cation to both the referring doctor and the patient's family.
Second, I would like to clarify our position on the use of
intracardiac repair in children under I year of age. In several
of the diagnoses discussed by the authors, this age grouping
provides an unrealistic view of the overall results. In TGA,
for instance, we find that the results of intracardiac repair
beyond the age of 3 months are exactly comparable with the
results of this operation in any older age group. With tetral-
ogy of Fallot, we have found the break point to be somewhere
around 6 months of age. With intracardiac repair of this lesion
beyond age 6 months, the results obtained are comparable
with results obtained in older age groups.
With this in mind, I think it would be appropriate for the
authors to comment more specifically on their results in the
very young age groups, specifically, those under 2 months of
age.
In viewing the reports from other centers addressing this
particular age group, we believe that the overall results fail to
justify a tremendous enthusiasm to press for intracardiac re-
pair in these very young infants.
Finally, I would like to report that at this time we still favor
the Blalock-Taussig operation as the most desirable
systemic-pulmonary shunt; we use it almost exclusively. I
believe this operation can be performed with a high degree of
success and with minimal mortality and morbidity. We prefer
to use it on the right side, and we use interrupted suture
technique much in the same fashion as we do with coronary
arteries. At the time of anastomosis, we administer heparin
before clamping the vessels.
DR. T U R LEY (Closing)
Dr. Lindesmiths recent data support our finding that in-
creasingly Group 3 and group 4 patients constitute the paral-
leled group.
Palliation of congenital heart disease 20 1
In regard to surgical therapy, these patients all required
operation in infancy, not as an elective approach, because
they were severely symptomatic. In all four of the Group 2
lesions, we maintain that the severely symptomatic patient
can be most successfully treated by an early corrective repair.
As to the question of the relation of age to death rate, there
was no difference between patients with TGA who were less
than 3 months of age and those older than 3 months of age. In
the tetralogy group no deaths occurred in the 14 patients less
than 3 months of age, and all three deaths in the group with
VSD occurred in severely ill infants, two of whom had re-
quired ventilator support from birth. The patients in whom
complex intraventricular repair is necessary, for example,
those with truncus arteriosus, are at a higher risk. The prob-
lem lies with the ventriculotomy and the nature of the ven-
tricular tissue in the first 6 weeks, for the ventricle in these
infants is edematous and much more difficult to suture ef-
fectively.
As I stated, however, these were severely symptomatic
patients and the alternative would have been pulmonary artery
banding, which in our hands has been unsuccessful in the
infant with truncus arteriosus.
Our method of cardiopulmonary support in these patients
had been to restrict the use of deep hypothermia and circula-
tory arrest to those less than 6 months of age, in whom the
operative repair can be done during less than 40 minutes of
circulatory arrest, for example, the transposition group.
In the case of the ventricular repairs, for example, the
truncus group, we have used core cooling to approximately
28° C and low flow during the intraventricular portion of the
repair, flows of about 10 cc/kg, allowing a relatively blood-
less field during the time of actual ventricular repair.