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The Waterston Shunt: A Commentary
CLASSICS IN THORACIC SURGERY
The Waterston Shunt: A Commentary Arthur DeBoer, M.D.
The Waterston shunt was first discussed in the medical literature in 1962 in an article published in a Czechoslovakian journal as a dedication to the 60th birthday of Professor V. Kalek [I]. The Waterston operation is a side-to-side anastomosis between the ascending aorta and the right pulmonary artery, and Waterston [l]probably was the first to mention the use of the subclavian artery as a free graft between the descending aorta and pulmonary artery. Waterston also recommended the use of this type of systemic-pulmonary shunt in cyanotic patients under 1 year of age, as it afforded relief of the cyanosis and was essential to survival. For several years after its introduction, the Waterston shunt was considered the operation of choice if a palliative procedure were contemplated. Interestingly, Waterston published his technique more than 15 years after the more popular shunt procedure described by Blalock and Taussig [2] in 1945 and Potts and colleagues (31 in 1946. Waterston probably presented his shunt procedure so much later because of the reported failures and disadvantages of the Blalock and Potts shunts. By 1961 it had become evident that the Blalock shunt sometimes failed in infants because of kinking of the subclavian artery or because the artery was too short and that the Potts shunt presented a difficult problem when total repair of the anomaly was attempted. In 1966, Edwards and co-workers [4] published an article describing a side-to-side anastomosis between the ascending aorta and right pulmonary artery. They stated that this procedure had not been reported before. Obviously, the procedure had been published before, but in a journal not commonly read, and thus was unknown to most surgeons, including the authors. The same procedure again was described in 1966 by authors Cooley and Hallman [5]. They apparently were either unaware of Waterston’s earlier publication, or misinterpreted Waterston’s procedure as different from theirs. Probably as a result of this article, the Waterston shunt sometimes has been referred to as the Waterston-Cooley anastomosis. Had the Waterston procedure been reported in a more widely read journal, its popularity more than likely would have been greater and its origin less controversial. From 1965 to well into the early 1980s, several publicaFrom the Division of Cardiothoracic Surgery, Department of Surgery, Northwestern University Medical School, Chicago, IL. Address reprint requests to Dr. DeBoer, Division of Cardiothoracic Surgery, Deparhnent of Surgery, 303 E. Chicago Ave, Ward 9-105, Chicago, IL 60611.
326 Ann Thorac Surg 44:326-327, Sep 1987
tions [6-81 reported complications of the Waterston shunt, resulting in kinking of the pulmonary artery. A kink in the pulmonary artery proximal to the anastomosis directed the entire shunt into the right lung and created pulmonary hypertension. A kink distal to the anastomosis directed the flow into the left lung. Any distortion of the pulmonary artery by the anastomosis created problems of stenosis of the right pulmonary artery when the shunt was closed at the time of complete repair. As the operation became more widely used, the incidence of heart failure in the immediate postoperative period increased as a result of an overly large shunt [9]. In time, and with follow-up, the shunt’s limitations became apparent: it was difficult to assess the size of the anastomosis and to restore the pulmonary arteries to normalcy during total repair. Thus, the use of the Waterston shunt as an elective procedure soon declined, and indications became more specific. If one capitalizes on the experiences of the past, however, the Waterston shunt can be a useful, low-risk operation, especially if two technical points are kept in mind. First, the anastomoses must be made as far posteriorly on the aorta as possible to avoid kinking of the right pulmonary artery. Second, the opening should be no larger than 4 mm measured on the undamped aorta. In assessing the need for a palliative shunt instead of a complete reparative procedure, two questions must be considered. If the cardiac anomaly is totally reparable, is the mortality of the reparative procedure less than the combined mortality of a palliative procedure plus the delayed reparative one? Is the primary reparative operation as good as or better than the delayed procedure if long-term results are considered? As yet, the final answers are not complete. Nevertheless, the Waterston shunt has played a major role in the palliative treatment of congenital cyanotic heart disease, and Waterston unquestionably should be credited as the originator of the intrapericardial ascending-aorta-to-right-pulmonary-artery anastomosis.
References 1. Waterston DS: Treatment of Fallot’s tetralogy in infants under the age of one year. Rozhl Chir 41:181, 1962 2. Blalock A, Taussig HG: Surgical treatment of malformations of the heart in which there is pulmonary stenosis or pulmonary atresia. JAMA 128:189, 1945 3. Potts WJ, Smith S, Gibson S: Anastomosis of the aorta to a pulmonary artery: certain types in congenital heart disease. JAMA 132:627, 1946 4. Edwards WS, Mohtashemi M, Holdefer WF: Ascending
327
Classic: DeBoer: The Waterston Shunt
aorta to right pulmonary artery shunt for infants with tetralogy of Fallot. Surgery 59316, 1966 5. Cooley D, Hallman G: Intrapericardial aortic-right' pulmonary arterial anastomosis. Surg Gynecol Obstet 122:1084, 1966
6. Levin DC, Fellows KE, Sos TA: Angiographic demonstration
of complications resulting from the Waterston procedure. Am J Roentgen01 131:431, 1978 7. Rao PS, Ellison RG: The cause of kinking of the right pulmo-
nary artery in the Waterston anastomosis: a growth phenomenon. J Thorac Cardiovasc Surg 76:126, 1978 8. Wilson JM. Mark JW, Turley K, Ehert P: Persistent stenosis and deformity of the right pulmonary artery after correction of the Waterston anastomosis. J Thorac Cardiovasc Surg 82169, 1981 9. Tay DJ, Engle MA, Ehlersf KH, Elvin AR: Early results and late developments of the Waterston anastomosis. Circulation 50:220, 1974
Circulatory Support 1988 Adam's Mark Hotel, St. Louis, Missouri February 6-7, 1988 (weekend meeting) Circulatory Support 1988 will be a comprehensive meeting on the clinical application of circulatory support devices. Surgeons, perfusionists, engineers, and operating room and intensive care unit nurses are encouraged to attend either individually or as a team. The meeting is sponsored by The Society of Thoracic Surgeons under the direction of its Committee on Circulatory Assist Devices and Artificial Hearts. Committee members are: D. Glenn Pennington, M.D., Chairman; Jack G. Copeland, M.D.; Charles Hahn, M.D.; J. Donald Hill, M.D.; George J. Magovern, M.D.; Peer M. Portner, Ph.D.; and M. Glenn Rahmoeller. For this weekend meeting, the Saturday morning segment entitled "Problem Cases" will include panel discussions on such topics as Patient Selection, Intraoperative Management, and Bleeding and Anti-Coagulation. Saturday afternoon will be divided in two parts, the first being a unique series of video presentations on the working details of currently available support devices.
The second Saturday afternoon session will offer attendees break-out meetings divided into concurrent sessions for surgeons, perfusionists/engineers,and OWICU nurses on the subjects of (1) Ecmo, Roller, and Centrifugal Pumps, (2) External Pulsatile Pumps, and (3) Internal Pulsatile Pumps. Sunday morning will be devoted to a state-of-the-art session with discussions focusing on such topics as Resuscitation for Cardiac Shock, Post Cardiotomy Support, Bridging to Transplant, Permanent Artificial Hearts, and Devices of the Future. In addition, there will be commercial exhibits related directly to program topics (by invitation only), and scientific posters will be used to show how circulatory devices are being used throughout the U.S. and elsewhere. For registration and other meeting information contact: The Society of Thoracic Surgeons, 111 East Wacker Dr, Chicago, IL 60601; tel: (312) 644-6610.
The Waterston Shunt: A Commentary Arthur DeBoer, M.D.
The Waterston shunt was first discussed in the medical literature in 1962 in an article published in a Czechoslovakian journal as a dedication to the 60th birthday of Professor V. Kalek [I]. The Waterston operation is a side-to-side anastomosis between the ascending aorta and the right pulmonary artery, and Waterston [l]probably was the first to mention the use of the subclavian artery as a free graft between the descending aorta and pulmonary artery. Waterston also recommended the use of this type of systemic-pulmonary shunt in cyanotic patients under 1 year of age, as it afforded relief of the cyanosis and was essential to survival. For several years after its introduction, the Waterston shunt was considered the operation of choice if a palliative procedure were contemplated. Interestingly, Waterston published his technique more than 15 years after the more popular shunt procedure described by Blalock and Taussig [2] in 1945 and Potts and colleagues (31 in 1946. Waterston probably presented his shunt procedure so much later because of the reported failures and disadvantages of the Blalock and Potts shunts. By 1961 it had become evident that the Blalock shunt sometimes failed in infants because of kinking of the subclavian artery or because the artery was too short and that the Potts shunt presented a difficult problem when total repair of the anomaly was attempted. In 1966, Edwards and co-workers [4] published an article describing a side-to-side anastomosis between the ascending aorta and right pulmonary artery. They stated that this procedure had not been reported before. Obviously, the procedure had been published before, but in a journal not commonly read, and thus was unknown to most surgeons, including the authors. The same procedure again was described in 1966 by authors Cooley and Hallman [5]. They apparently were either unaware of Waterston’s earlier publication, or misinterpreted Waterston’s procedure as different from theirs. Probably as a result of this article, the Waterston shunt sometimes has been referred to as the Waterston-Cooley anastomosis. Had the Waterston procedure been reported in a more widely read journal, its popularity more than likely would have been greater and its origin less controversial. From 1965 to well into the early 1980s, several publicaFrom the Division of Cardiothoracic Surgery, Department of Surgery, Northwestern University Medical School, Chicago, IL. Address reprint requests to Dr. DeBoer, Division of Cardiothoracic Surgery, Deparhnent of Surgery, 303 E. Chicago Ave, Ward 9-105, Chicago, IL 60611.
326 Ann Thorac Surg 44:326-327, Sep 1987
tions [6-81 reported complications of the Waterston shunt, resulting in kinking of the pulmonary artery. A kink in the pulmonary artery proximal to the anastomosis directed the entire shunt into the right lung and created pulmonary hypertension. A kink distal to the anastomosis directed the flow into the left lung. Any distortion of the pulmonary artery by the anastomosis created problems of stenosis of the right pulmonary artery when the shunt was closed at the time of complete repair. As the operation became more widely used, the incidence of heart failure in the immediate postoperative period increased as a result of an overly large shunt [9]. In time, and with follow-up, the shunt’s limitations became apparent: it was difficult to assess the size of the anastomosis and to restore the pulmonary arteries to normalcy during total repair. Thus, the use of the Waterston shunt as an elective procedure soon declined, and indications became more specific. If one capitalizes on the experiences of the past, however, the Waterston shunt can be a useful, low-risk operation, especially if two technical points are kept in mind. First, the anastomoses must be made as far posteriorly on the aorta as possible to avoid kinking of the right pulmonary artery. Second, the opening should be no larger than 4 mm measured on the undamped aorta. In assessing the need for a palliative shunt instead of a complete reparative procedure, two questions must be considered. If the cardiac anomaly is totally reparable, is the mortality of the reparative procedure less than the combined mortality of a palliative procedure plus the delayed reparative one? Is the primary reparative operation as good as or better than the delayed procedure if long-term results are considered? As yet, the final answers are not complete. Nevertheless, the Waterston shunt has played a major role in the palliative treatment of congenital cyanotic heart disease, and Waterston unquestionably should be credited as the originator of the intrapericardial ascending-aorta-to-right-pulmonary-artery anastomosis.
References 1. Waterston DS: Treatment of Fallot’s tetralogy in infants under the age of one year. Rozhl Chir 41:181, 1962 2. Blalock A, Taussig HG: Surgical treatment of malformations of the heart in which there is pulmonary stenosis or pulmonary atresia. JAMA 128:189, 1945 3. Potts WJ, Smith S, Gibson S: Anastomosis of the aorta to a pulmonary artery: certain types in congenital heart disease. JAMA 132:627, 1946 4. Edwards WS, Mohtashemi M, Holdefer WF: Ascending
327
Classic: DeBoer: The Waterston Shunt
aorta to right pulmonary artery shunt for infants with tetralogy of Fallot. Surgery 59316, 1966 5. Cooley D, Hallman G: Intrapericardial aortic-right' pulmonary arterial anastomosis. Surg Gynecol Obstet 122:1084, 1966
6. Levin DC, Fellows KE, Sos TA: Angiographic demonstration
of complications resulting from the Waterston procedure. Am J Roentgen01 131:431, 1978 7. Rao PS, Ellison RG: The cause of kinking of the right pulmo-
nary artery in the Waterston anastomosis: a growth phenomenon. J Thorac Cardiovasc Surg 76:126, 1978 8. Wilson JM. Mark JW, Turley K, Ehert P: Persistent stenosis and deformity of the right pulmonary artery after correction of the Waterston anastomosis. J Thorac Cardiovasc Surg 82169, 1981 9. Tay DJ, Engle MA, Ehlersf KH, Elvin AR: Early results and late developments of the Waterston anastomosis. Circulation 50:220, 1974
Circulatory Support 1988 Adam's Mark Hotel, St. Louis, Missouri February 6-7, 1988 (weekend meeting) Circulatory Support 1988 will be a comprehensive meeting on the clinical application of circulatory support devices. Surgeons, perfusionists, engineers, and operating room and intensive care unit nurses are encouraged to attend either individually or as a team. The meeting is sponsored by The Society of Thoracic Surgeons under the direction of its Committee on Circulatory Assist Devices and Artificial Hearts. Committee members are: D. Glenn Pennington, M.D., Chairman; Jack G. Copeland, M.D.; Charles Hahn, M.D.; J. Donald Hill, M.D.; George J. Magovern, M.D.; Peer M. Portner, Ph.D.; and M. Glenn Rahmoeller. For this weekend meeting, the Saturday morning segment entitled "Problem Cases" will include panel discussions on such topics as Patient Selection, Intraoperative Management, and Bleeding and Anti-Coagulation. Saturday afternoon will be divided in two parts, the first being a unique series of video presentations on the working details of currently available support devices.
The second Saturday afternoon session will offer attendees break-out meetings divided into concurrent sessions for surgeons, perfusionists/engineers,and OWICU nurses on the subjects of (1) Ecmo, Roller, and Centrifugal Pumps, (2) External Pulsatile Pumps, and (3) Internal Pulsatile Pumps. Sunday morning will be devoted to a state-of-the-art session with discussions focusing on such topics as Resuscitation for Cardiac Shock, Post Cardiotomy Support, Bridging to Transplant, Permanent Artificial Hearts, and Devices of the Future. In addition, there will be commercial exhibits related directly to program topics (by invitation only), and scientific posters will be used to show how circulatory devices are being used throughout the U.S. and elsewhere. For registration and other meeting information contact: The Society of Thoracic Surgeons, 111 East Wacker Dr, Chicago, IL 60601; tel: (312) 644-6610.