Immediate Post-operative Management of

Blalock- Taussig Shunt (BTS)

Royal Hospital for Sick Children

PICU

Immediate Post-op Version: 1.0 Page 1 of 11

Management of BT shunt
Author: Colin Begg Authorised by: PICU Group Issue Date: July 2010
Date of Review: October 2015 Q-Pulse Ref: YOR-PICU-006
 Contents Page Number(s)
1. Background 2
2. Anticoagulation management 4
3. Management of Blocked BT Shunt 6
4. Management of Over-circulation 8

1. Rationale/Purpose/Objective

• To allow standardised management of anticoagulation in patients

with a Blalock-Taussig Shunt in PICU
• Provide evidence base for management of a suspected blocked BT
shunt.
• Provide educational material to assist staff managing a child with a
BT shunt in the PICU.

2. Scope

• This guideline applies to the immediate post-operative management

of any patient with a Blalock-Taussig Shunt in PICU.

3. Roles and responsibilities

• All healthcare professionals involved in caring for a post-operative

cardiac patient in the PICU should be aware of this guideline.

4. Evidence
• The guidelines are constructed after consultation with standard
textbooks, a medline search (BT shunt, systemic to pulmonary
shunt, blocked shunt, occluded shunt, shunt failure, Streptokinase
and shunt, TPA and shunt, thrombolysis, aspirin, heparin, warfarin,
anticoagulation and shunt, anticoagulation in children) and local
expert opinion. The best available levels of evidence were used to construct
these guidelines. Level 1 evidence is lacking in this area.

1. Background
The Blalock- Taussig shunt (BTS) was first described in the 1940’s. The Classical
BTS was a direct anastomosis of the subclavian to the pulmonary artery(PA). This
developed into the Modified BT shunt in the 1970’s - Right or left subclavian
artery to branch PA with a Gore-Tex shunt, this is the type of shunt that will be
found on the unit today. 1-3

The annual number of BT shunts being performed has fallen over the last 20
years. This is largely due to advancing surgical technique. BT shunts were
originally used predominately in the management of Tetralogy of Fallot (TOF),
now most TOF go straight to a full repair. BTS however remains an option for
infants; particularly those that are unstable at presentation or who have
anatomical considerations that prevent early total correction.1-3

Although the overall numbers of BT shunts being inserted has fallen, increasing
proportions are being used in the management of the single ventricle patient.
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Management of BT shunt
Author: Colin Begg Authorised by: PICU Group Issue Date: July 2010
Date of Review: October 2015 Q-Pulse Ref: YOR-PICU-006
This has coincided with an increased length of stay of shunt babies in the ICU.
The mean length of stay for an uncomplicated shunt is 3 days.4 A BT shunt may
be placed in isolation or increasingly may be part of a more complex operation
such as the Stage 1 Norwood for the hypoplastic left heart.2,3

The BT shunt is usually inserted to increase blood to flow to the lungs. The size
and length of the shunt in part determine the amount of blood flow to the lungs.
If the shunt is too big this may lead to relatively excessive pulmonary blood flow
and high saturations described as pulmonary overcirculation. This may reveal
itself with oedematous lungs, heart failure and poor systemic perfusion. The
current trend would be to place as big a shunt as possible and allow the baby to
grow into it, meanwhile managing the circulation with diuretics. If a shunt is too
big this may lead to difficulties when ventilation is weaned. The shunt may
occasionally be clipped or taken-down. This may need to be done quickly if low
diastolic pressure is compromising the coronary circulation. Pulmonary
overcirculation may also present with systemic hypoperfusion. This may be
revealed with low blood pressure, low mixed venous saturations and a rising base
excess and lactate. 1 2,3,5,5-7
If the shunt is too small the baby will be desaturated and inadequate pulmonary
perfusion will lead to hypoxia and poor oxygen delivery to tissues.5-7
Obviously there is a careful balancing act between pulmonary and systemic
perfusion. When a BT shunt is inserted there is a dramatic change in physiology
from the pre-operative state. “It’s just a shunt” should be a phrase banned from
the intensive care. In the postoperative period attention to detail is required as
there can be frequent haemodynamic shifts as the cardiovascular system
readjusts.5

The immediate post operative period is a time where the incidence of shunt
failure is high. This can present acutely with precipitously dropping saturations.
Acute shunt failure is usually secondary to the shunt clotting off or kinking. This is
an emergency and the management is discussed below.1,5,8

The incidence of shunt thrombosis is reported at 12%.9 Prevention of clot

formation within shunts is controversial. Some studies have suggested that
aspirin may reduce rate of shunt thrombosis while others have failed to prove
this.9-11,11,12 The use of heparin post-operatively is also controversial, some
believe it is unnecessary and may be linked to causation of seromas.10,13 Shunts
all have an attrition rate; a study looking at the histopathology of shunts
electively taken down found 21% had a 50% stenosis at a median age of 8
months. Smaller shunts were more likely to stenose.3,7 Many centres anti-
coagulate. Our current anticoagulation guideline is displayed on the following
pages.

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Management of BT shunt
Author: Colin Begg Authorised by: PICU Group Issue Date: July 2010
Date of Review: October 2015 Q-Pulse Ref: YOR-PICU-006
 2. Anticoagulation management

Introduction of anti-coagulant therapy with heparin should be instituted as

soon as safely possible after theatre. Confirm with the consultant surgeon
at handover that there are not specific reasons to avoid the following
standard approach. Patients are usually given heparin in theatre.
Commence heparin when bleeding is not an issue (chest drains are
bleeding less than 3 ml/kg/hr) and the post-op APTT is less than 60.
Generally heparin is not titrated to APTT unless there is a specific surgical
request.

Heparin therapy should be managed as follows:

a) Standard heparin regime for prophylaxis10,14

Prepare infusion using 1000units/kg of heparin sodium, diluted to 50ml

with 0.9% sodium chloride.

Infusion is commenced at 10 units/kg/hr (0.5 ml/hr).

Monitoring:
o Clotting profile (APTT, PT and fibrinogen) should be checked
As follows:
o Prior to commencement of heparin
o 4-6 hours after INITIAL commencement
o One hour after a syringe is changed
o Daily whilst on heparin infusion
This is to ensure the patient’s APTT does not rise too high (>80)

o Platelets
o Daily
If platelets drop by >50% from baseline consider Heparin Induced
Thrombocytopenia (HIT), this is most likely 5-10 days of treatment.
However there are many other reasons for thrombocytopenia (NEC
/infection etc) Notify consultant. Consider HIT antibody screen.

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Management of BT shunt
Author: Colin Begg Authorised by: PICU Group Issue Date: July 2010
Date of Review: October 2015 Q-Pulse Ref: YOR-PICU-006
b) Therapeutic heparin regime10,14

Not routine - specific surgical request

Titrate heparin to achieve an APTT of 60-90

Prepare infusion using 1000units/kg of heparin sodium, diluted to 50ml
with 0.9% sodium chloride.

Loading dose is not required if recently returned from cardiac theatre

• ONLY IF APTT <50s: Initial loading dose of 50units/kg (2.5ml)
over ten minutes.
• IF APTT 50-90s: Run infusion at 20units/kg/hr (1ml/hr) and
check APTT in 4 hours. Manage as follows:

aPTT (s) Bolus Stop Rate Recheck

(units/kg) infusion Change APTT (hr)
<50 50 +10% 4
50-59 4
60-90 Next day
91-99 -10% 4
100-120 30min 4
>120 60min -15% 4

Most importantly any change in heparin dosage should be followed by a

repeat clotting profile at 4 hours.
The need for more than 30 units/kg/hr of heparin to achieve APTT should
be made known to the consultant.
Consider measuring anti-Xa level or anti-thrombin III level. This will be
age dependent. It is not unusual for a child<1 to require 28units/kg/hr to
achieve therapeutic APTT levels.
Once the APTT is achieved and the heparin infusion is stable – once daily
clotting profile is acceptable.

o Platelets
o Check once a day whilst on heparin
o If platelets drop by >50% from baseline consider
Heparin Induced Thrombocytopenia (HIT), this is more
likely after 5 -10 days of treatment. However there are
many other reasons for thrombocytopenia (NEC
/infection etc) Notify consultant. Consider HIT
antibody screen.
c) Aspirin
Must fulfill the following criteria to start aspirin:
1. Chest closed
2. Major intracardiac lines removed (pulmonary arterial/ left atrial lines)
3. Pacing wires out
4. Absorbing feed
Aspirin is commenced at 3-5mg/kg (max 75mg) once daily. Continue
heparin until the second dose of aspirin is given.

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Management of BT shunt
Author: Colin Begg Authorised by: PICU Group Issue Date: July 2010
Date of Review: October 2015 Q-Pulse Ref: YOR-PICU-006
 5,6,9,15
2. Management of a Suspected Blocked BT Shunt

This is an emergency

Diagnosis
Consider in any patient who has a significant sustained desaturation
with a systemic to pulmonary cardiac shunt, or whose saturations drop
and a shunt murmur is no longer audible.
Most likely to occur in a new shunt or in a dehydrated patient known to
have a shunt. It is also more likely if flow is competing with an open duct
(PDA).

Check the obvious:

Desaturation can frequently be respiratory in nature.
DOPE (Displaced ET position, Obstructed ET, Pneumothorax, Equipment
failure)
Auscultate – previous obvious shunt murmur will have disappeared
Check gas - ?low PaO2, rising lactate, correct acidosis
Review most recent APTT.
If the shunt is blocked the patient will profoundly desaturate.
This will be followed by hypotension.
In the worst case if not resolved this will lead to death

Principle of management …. Think shunt.

Think could shunt have blocked? Act quickly.

Management 5,6,15
Resuscitate – A,B,C
Request Urgent Echo
Inform surgeon and cardiologist immediately.
Do not wait for Echo – if suspicious start management and escalate as
necessary.
Call surgeon immediately there is concern shunt may have blocked –
do not wait.

Meanwhile

1. Hand ventilate
2. Bolus sedation
3. Increase SVR – Stepwise
a) 5ml/kg aliquots of 4% human albumin volume
b) Phenylephrine
(The dose is 3-10microgram/kg. Dilute 10mg in
50ml 5% glucose and give 0.02-0.05ml/kg as a slow IV injection)
c) Start or increase dopamine infusion
d) Start noradrenaline infusion
4. Reduce PVR - Sedate and consider paralysis
Hand ventilate – decrease pCO2 – aim alkalosis.
Oxygenate

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Management of BT shunt
Author: Colin Begg Authorised by: PICU Group Issue Date: July 2010
Date of Review: October 2015 Q-Pulse Ref: YOR-PICU-006
 Consider bolus magnesium sulphate –
(0.4mmoll/kg magnesium sulphate 50%)
5. Bolus heparin 50 units/kg
6. Start heparin infusion at 20 units/kg/hr or increase heparin infusion
if already running.
7. Restart prostaglandin in neonate.
8. Consider second bolus of heparin 50 units/kg
9. Consider Tissue Plasminogen Activator (alteplase) * Decision by
Intensivist, Cardiologist and Consultant surgeon.
10. Decide for catheter or surgical intervention. **

*There are case reports that suggest recombinant tissue plasminogen

activator (alteplase) may be successful in unblocking shunts. However
its use must be considered carefully. A relative contraindication for
use is recent surgery. Contra-indicated if surgery within 10 days or
active bleeding.10,14,16,17

TPA (alteplase) is short acting, it binds selectively to fibrin-clot bound

plasminogen and activates to form the fibrinolytic plasmin. It has a
plasma half-life of 4-5 mins. Less than 10% remains 20 minutes after
it is stopped, but bleeding tendency can persist for much longer. The
case reports vary in method of administration between systemic
treatment and directly administered into shunt. Local administration
has been reported with 0.1mg/kg and 0.2 mg/kg boluses followed by a
systemic infusion of 1mg/kg for 24 hours. However doses being used
to clear arterial and venous thrombi in children have been much lower
than this < 0.1mg/kg/hr for 12 hours. Dosage is therefore an
issue.3,10,14,17-19 The BNF-C recommends a dose of 100-
500micrograms/kg/hour for 3 to 6 hours with follow up imaging. Max
of 100mg/day.
In view of these controversies TPA (alteplase) should only be
given for shunt blockage with agreement of the consultant
intensivist, cardiologist, and surgeon.
On consultation with haematology the following dose schedule has
been agreed:

Tissue plasminogen activator (alteplase). Stop heparin infusion.

In neonate give 10ml/kg of FFP prior to commencing TPA(alteplase).
Dose Investigations Ensure
0.1 -0.6mg/kg/hr 3 hourly
Start at low dose
and titrate up if no FBC, Coag screen Platelets >100
complications. Can including d-dimers Fibrinogen>2
be given for>6hrs (d-dimers should climb as
thrombolysis occurs)
closely monitored
6 hourly
Review of clot with
imaging

Standard thrombolytic therapy should be followed with a heparin

infusion aiming for an APTT of 60-90.10,14,17
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Management of BT shunt
Author: Colin Begg Authorised by: PICU Group Issue Date: July 2010
Date of Review: October 2015 Q-Pulse Ref: YOR-PICU-006
**Cardiac catheter may be useful from a diagnostic and interventional
viewpoint. ECHO does not always demonstrate clot, angiography may
help if there is doubt regarding diagnosis. Clot destruction via catheter
has been demonstrated and may be an option in some specific
circumstances.16,19,22 -25

However if there is any concern regarding surgical repair or a

deteriorating child despite above interventions– return to theatre should
not be delayed.

3. Management of Pulmonary Over-circulation

The management of pulmonary over-circulation can be complex and is

dependent on the anatomy and physiology of the underlying lesion. The
following is only a beginners guide to recognising and managing this
difficult problem. Consultant input is essential.

If the BT shunt is too big this may lead to relatively excessive pulmonary
blood flow and high saturations described as pulmonary over-circulation.
This is more common if the ductus arteriosus is still open and may resolve
as the duct closes.
Pulmonary over-circulation may reveal itself in the early post-operative
period or become more problematic when ventilation is weaned.

Diagnostic clues
Relatively high saturations
CXR- oedematous lungs
Low mixed venous saturations
Rising lactate
Increase in base deficit
Often tachycardic
May have relatively low mean blood pressure
Widening toe core gap
Review NIRS – decreased splanchnic and then cerebral saturations
Signs of right heart failure e.g large liver, ascites(late sign)

Important to review diastolic pressure – if low this may compromise

coronary flow.
Look for signs of ischaemia –ECG changes

Treatment
Mild form may be treated simply with fluid restriction and diuretics.
As this becomes more problematic, manipulation of pulmonary and
systemic vascular resistance(PVR and SVR) is required.

If ECG changes are present this is an emergency. Inform intensive care

consultant
Repeat Echo and 12-lead ECG.
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Management of BT shunt
Author: Colin Begg Authorised by: PICU Group Issue Date: July 2010
Date of Review: October 2015 Q-Pulse Ref: YOR-PICU-006
Increase PVR
Reduce oxygen
Increase PEEP
Allow pCO2 to rise gently

Reduce SVR
Consider reducing vasopressor therapy slowly
Consider vasodilation – eg. Milrinone or SNP (discuss with intensive care consultant)
Overcirculation may also be present in conjunction with a low cardiac
output state therefore inotropy may be required.

The shunt may occasionally need to be clipped or taken-down. This may

need to be done quickly if low diastolic pressure is compromising the
coronary circulation. 1 2,3,5,5-7

This guideline will be reviewed every 2 years.

Reference List

1. Williams,J.A. et al. Two thousand Blalock-Taussig shunts: a six-

decade experience. Ann. Thorac. Surg. 84, 2070-2075 (2007).

2. Bove,E.L. et al. The modified Blalock-Taussig shunt: analysis of

adequacy and duration of palliation. Circulation 76, III19-III23
(1987).

3. Gladman,G., McCrindle,B.W., Williams,W.G., Freedom,R.M. &

Benson,L.N. The modified Blalock-Taussig shunt: clinical impact and
morbidity in Fallot's tetralogy in the current era. J. Thorac.
Cardiovasc. Surg. 114, 25-30 (1997).

4. Swain,S.K. et al. Neonatal Blalock-Taussig shunt: technical aspects

and postoperative management. Asian Cardiovasc. Thorac. Ann.
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Management of BT shunt
Author: Colin Begg Authorised by: PICU Group Issue Date: July 2010
Date of Review: October 2015 Q-Pulse Ref: YOR-PICU-006
 9. Li,J.S. et al. Clinical outcomes of palliative surgery including a
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Immediate Post-op Version: 1.0 Page 10 of 11
Management of BT shunt
Author: Colin Begg Authorised by: PICU Group Issue Date: July 2010
Date of Review: October 2015 Q-Pulse Ref: YOR-PICU-006
 recanalization with intravenous streptokinase. Am Heart J. 120,
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Management of BT shunt
Author: Colin Begg Authorised by: PICU Group Issue Date: July 2010
Date of Review: October 2015 Q-Pulse Ref: YOR-PICU-006