Early Results and Late Developments of the Waterston Anastomosis

Abstract

The early results and late developments are presented of a consecutive series of 36 patients who underwent anastomosis of the ascending aorta to right pulmonary artery during a six-year period for a variety of congenital malformations associated with cyanosis and severe pulmonary stenosis or atresia. Twenty-six were infants under one year of age, and 16 of these were under one month of age at the time of operation. The early operative mortality of 22% was related to the severity of the anomaly and the young age of the patient. There were no early deaths in those aged three months or more. If the anastomosis was patent, symptomatic relief was good. However, the long-term mortality was 53%. Except for one baby who died of an associated congenital anomaly, the deaths were related to some consequence of the Waterston anastomosis that was unforeseen at the time of its employment. These included obliteration of the anastomosis, kinking of the anastomosis with partial or complete interruption of continuity between right and left pulmonary arteries, obliteration of the right pulmonary artery, progressive severe obstruction to right ventricular outflow and decreased flow to the left lung, as well as the complications of an excessive shunt with cardiac failure and pulmonary vascular obstructive disease. One or more subsequent palliative operations were required in nine symptomatic patients. Of the ten children with tetralogy of Fallot who underwent later open-heart repair, four died because of the difficulty in takedown of the Waterston and relief of the acquired stenosis or atresia of the right pulmonary artery and of the right ventricular outflow tract and hypoplasia of the left pulmonary artery. This mortality rate of 40% in these tetralogies contrasts with a concurrent mortality rate of less than 5% in a consecutive series of 50 patients with a tetralogy who had not had a previous Waterston procedure. We believe that this form of palliation should be reserved for those symptomatic, cyanotic newborns who are candidates for palliative rather than reparative surgery and who are not suitable for a Blalock-Taussig or Potts anastomosis.