We sincerely appreciate the thoughtful comments[1] regarding our recent systematic review and meta-analysis on the modified Blalock-Taussig- Thomas (mBT) shunt.[2]

Advances in neonatal anesthesia, cardiopulmonary bypass (CPB), and perioperative care have, indeed, enabled early complete repair in many cases. Furthermore, interventional procedures such as right ventricular outflow tract (RVOT) stenting have demonstrated certain advantages including lower admission rates to the pediatric intensive care unit (ICU), shorter total hospital length of stay, and earlier timing to definitive surgical repair.[3]

Nevertheless, not all patients are suitable candidates for early total correction. Infants with small right and left pulmonary arteries are at risk of right ventricular failure due to elevated right ventricular pressures if a complete repair is attempted too early, thereby leading to inadequate pulmonary blood flow or persistent cyanosis. In addition, premature infants, those with low birth weight, and those with oxygen saturations <70% still remain at significantly higher risk while undergoing early complete repair. For such patients, the mBT shunt continues to be recognized as the most common surgical palliative procedure for symptomatic neonates with tetralogy of Fallot.[4]

Successful early repair also requires the availability of specialized infrastructure, including a dedicated pediatric cardiac ICU, extracorporeal membrane oxygenation support, and an experienced perfusion team. In Indonesia, however, not all tertiary centers are able to perform RVOT stenting or early total correction. By contrast, the mBT shunt usually does not require CPB in routine cases, although it is advisable to have CPB on standby in complex scenarios.[5]

We agree that the trend toward early correction is reshaping surgical strategies, and the role of the mBT shunt is becoming increasingly selective. Not all patients require an mBT shunt prior to total correction if the pulmonary arteries are adequately developed. However, until early repair becomes universally feasible, the mBT shunt will remain a critical component in the armamentarium of congenital cardiac surgery. In our review, we attempt to highlight complications associated with this procedure, thereby helping clinicians to anticipate and manage them more effectively.

Thank you for contributing to this important discussion.

Data Sharing Statement: The data that support the findings of this study are available from the corresponding author upon reasonable request.

Author Contributions: Refines, extends, and challenges existing theories: A.D.I.; Provides new data from experiments or clinical studies: A.R.; Supervised and provided critical revision of the manuscript: S.W.

Conflict of Interest: The authors declared no conflicts of interest with respect to the authorship and/or publication of this article.