Surgery for congenital heart diseases
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Surgery for Congenital Heart Diseases. Seoul National University Children ’ s Hospital Yong Jin Kim,M.D. Etiologic Basis of Congenital Heart Diseases. 1. Primary genetic factors (10%) 1) Chromosomal; 5-10% 2) Single mutant gene; 3%

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Surgery for Congenital Heart Diseases

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Surgery for congenital heart diseases

Surgery for Congenital Heart Diseases

Seoul National University Children’s Hospital

Yong Jin Kim,M.D.


Etiologic basis of congenital heart diseases

Etiologic Basis of Congenital Heart Diseases

  • 1. Primary genetic factors (10%)

  • 1) Chromosomal; 5-10%

  • 2) Single mutant gene; 3%

  • Recessive

  • Dominant

  • 2. Genetic-environmental interaction (90%)

  • 1) Multifactorial inheritance; majority

  • 2) Risks to offspring of an affected parent

  • 3) Environmental contribution

  • Drugs

  • Infections

  • Maternal conditions


Potential cardiovascular teratogens

1. Drugs

Alcohol

Amphetamines

Anticonvulsants

Chemotherapy

Sex hormone

Thalidomide

Retinoic acid

2. Infections

Rubella

Coxsakie virus

3. Maternal conditions

Old age

Diabetes

Lupus

Phenylketonuria

4. Others

Potential Cardiovascular Teratogens


Maternal risk factors

Maternal Risk Factors

  • Factors Malformation

    Advanced age Trisomy 21

    Maternal CHD Various

    Diabetes mellitus VSD, TGA, cardiomyopathy

    SLE Heart block

    Phenylketonuria TOF, VSD, COA, HLHS

    Viruses Teratogenic, myocarditis

    (*cytomegalovirus,

    herpes, coxsacki B,

    parvovirus)


Maternal drug exposures

Maternal Drug Exposures

  • Drug Malformation

  • Diphenylhydantoin PS, AS

  • Trimetadione VSD, TOF, TGA, HLHS

  • Thalidomode TOF, Truncus arteriosus

  • Lithium Ebstein anomalies

  • Alcohol VSD, ASD, PDA, TOF

  • Amphetamine VSD, ASD, PDA, TGA

  • Birth control pills VSD, TOF, TGA


Stages of heart formation

Stages of Heart Formation

  • 1. Early blood vessel formation

  • 1) Intraembryonic blood vessel at 13 days

  • 2) Extraembryonic blood vessels at 17 days

  • 2. Development of heart

  • 1) Position and cardiac tube at 23 days

  • Heart beating at 26 days.

  • 2) Formation of heart loop at 8 somites

  • 3) Formation of ventricle

  • 4) Development of sinus venosus

  • 3. Formation of cardiac septa

  • 4. Formation of cardiac valves

  • 5. Formation of arterial system

  • 6. Formation of great systemic veins


Incidence of congenital heart diseases

1. Lt to Rt Shunt ( 53 % )

PDA 17 %

ASD 16.5 %

VSD 13 %

AVSD 3.5 %

Abn. PV return 3 %

2. Rt to Lt Shunt (11 % )

TOF 4.5 %

TA 3 %

PA+VSD 2.5 %

PA+IVS 0.5 %

3. Admixture Lesion( 15 % )

TGA 5 %

Univ. Ht. 5 %

Atrial isomerism < 2 %

DORV < 2 %

Truncus 0.8 %

Corrected TGA < 0.5 %

4. Obstructive Lesion ( 15 % )

Coarctation 9.5 %

PS 2 %

MS etc. 1.5 %

LVOTO 1.3 %

HLHS 0.9 %

IAA 0.6 %

5. Valvular Lesion

Ebstein < 1 %

AR < 0.5 %

MR < 0.5 %

SV aneurysm < 0.5 %

6. Miscellaneous

Arrhythmia 5 %

Vascular ring 0.5 %

Incidence of Congenital Heart Diseases


Evaluation of chd by history taking

1. Infants

1) Murmur

2) Symptoms of CHF

poor feeding,

low weight gain,

tachypnea, tachycardia,

sweating, anxiety,

irritability, frequent URI

3) Symptoms of hypoxemia

cyanosis, hypoxic spell

2. Children

1) Murmur

2) Symptoms of CHF

exercise intolerance,

dyspnea on exertion,

frequent URI,

palpitation

3) Syncope, chest pain

4) Symptoms of Hypoxemia

cyanosis,

hypoxic spell,clubbing

Evaluation of CHD by History Taking


To be corrected in neonate

To Be Corrected in Neonate

  • Critical AS

  • Hypoplastic left heart syndrome

    Mitral valve hypoplasia

    Aortic valve and arch hypoplasia

    Hypoplastic left ventricle

  • Interrupted aortic arch

  • Symptomatic COA

  • TGA

  • Obstructive TAPVC

  • Truncus Arteriosus

  • PA with IVS

  • PA with VSD

  • Other symptomatic complex heart diseases


To be corrected in infancy i

To Be Corrected in Infancy(I)

  • Cardiac anomalies with pulmonary outflow

    tract obstruction

    • Double inlet ventricle

    • Critical PS

    • Tricuspid atresia

    • DORV

    • DOLV

    • TGA

    • TOF

    • PA with or without VSD

    • Corrected TGA


To be corrected in infancy ii

Cardiac anomalies with CHF

Large VSD

AVSD

Double inlet ventricle

Tricuspid atresia

TAPVC

COA

DOLV

PA with IVS

Corrected TGA

Cardiac mass

TGA

Truncus arteriosus

Severe AS, AR

Severe MS, MR

Interrupted aortic arch

DORV

Aortopulmonary window

ALCAPA

PDA

TAPVR

To Be Corrected in Infancy(II)


To be corrected in infancy childhood

To Be Corrected in Infancy & Childhood

  • ASD

  • AS(LVOTO)

  • Partial AVSD

  • Ebstein’s anomaly

  • VSD with PS

  • VSD

  • PS

  • Mitral stenosis

  • Atrial isomerism

  • Coronary artery anomaly (A-V fistula)

  • Anomalous pulmonary venous drainage

  • Valvular heart diseases

  • Complex anomalies with previous palliation

  • Late presenting cardiac anomalies

  • Cardiomyopathy


Surgical indications and optimal timing of operation

Surgical IndicationsandOptimal Timing of Operation


Palliative surgery

Palliative Surgery

  • Systemic – pulmonary artery shunt

    Blalock-Taussig shunt

    Unifocalization and shunt

    Cavopulmonary shunt (BCPS)

  • RVOT reconstruction

    Valvotomy

    Patch widening

    Valved conduit

  • Pulmonary artery banding

  • Atrial septectomy


Systemic pulmonary artery shunt

Systemic–Pulmonary Artery Shunt

  • Systemic–pulmonary artery shunt is indicated due to age, size, anatomy or other conditions when:

  • Complex anomaly with severe cyanosis, irritability, hypoxic episode

  • Critically ill neonates or infants due to decreased pulmonary flow

  • Facilitating growth of hypoplastic pulmonary artery


Pulmonary artery banding

Pulmonary Artery Banding

  • Pulmonary artery banding is indicated to decrease

    pulmonary blood flow & protect vascular disease when:

  • Control of congestive heart failure

    Complex or multiple VSD (+/- coarctation)

    Single ventricle, Tricuspid atresia without PS

    CPB medically contraindicated

  • Protection of pulmonary vascular bed

    Single ventricle – Fontan operation

  • Preparation of LV for arterial switch operation

    TGA with IVS / restrictive VSD


Atrial septectomy

Atrial Septectomy

  • For the increasing of effective pulmonary

    flow and systemic oxygen saturation

  • Indication of atrial septectomy :

    TGA

    Tricuspid atresia

    Pulmonary atresia + IVS

    MV and LV hypoplasia

  • Decreasing tendency of indication due to early total correction or intervention


Reparative surgery

Reparative Surgery

  • Non-open heart surgery

    Open heart surgery

  • Palliative procedure

    Corrective procedure

    • Anatomic correction

    • Physiologic correction


Non open heart surgery

Non-open Heart Surgery

  • Palliative procedure

  • Corrective procedure

  • PDA

  • COA

  • Vascular ring and sling

  • Coronary artery anomalies

  • Stenotic valvular diseases

    • Inflow occlusion technique

    • Instrumental dilatation


Patent ductus arteriosus

Patent Ductus Arteriosus

  • Open communication usually between upper descending Ao and proximal portion of LPA

  • Significant PDA : indicated after 1st month

  • Prophylactic closure : 6-12 mo

  • Sx of heart failure or failure to thrive : indicated at any time

  • Severe pulmonary vascular disease : contraindicated


Coarctation of the aorta

Coarctation of the Aorta

  • Congenital narrowing of upper thoracic aorta adjacent

    to the ductus arteriosus

  • Operation is indicated when :

    Reduction of luminal diameter > 50%

    Upper body HT > 150mmHg in young infant

    With CHF at any age

  • COA with VSD

    Two stage repair

    One stage repair

  • COA with other important intracardiac defects

    One stage repair


Vascular ring

Vascular Ring

  • Anomalies of the great arteries that compress the trachea or esophagus

  • Double aortic arch

  • Rt aortic arch with retroesophageal anomalous Lt. SCA and ligamentum arteriosum

  • Rt aortic arch with retroesophageal ligamentum arteriosum

  • Operation is indicated when : Obstructive Sx and radiologic signs of obstruction

  • Division by thoracotomy

  • CPB in associated cardiac anomaly


Vascular sling

Vascular Sling

  • Lt. pulmonary artery arises anomalously from Rt pulmonary artery extrapericardially, form a sling around trachea

  • Sx & Signs of obstruction : indicated

    Tracheal anomaly or other airway problems (+)

    (ASD, VSD, PDA, Lt SVC)

  • Thoracotomy without CPB

  • Median sternotomy with CPB


Open heart surgery

Open Heart Surgery


Asd and papvr

ASD and PAPVR

A hole of variable size in the atrial septum and is

most common cardiac malformation with various

location of defect, fossa ovalis, posterior, ostium,

primum, coronary sinus, subcaval (sinus venosus)

Uncomplicated ASD or of PAPVC with RV volume

overload (Qp/Qs>1.5 or 2.0) : an indication

  • Scimitar syndrome

  • Isolated PAPVC

  • Optimal age : under 5 years but recently 1-2 years to avoid RV volume overload


Unroofed coronary sinus syndrome

Unroofed Coronary Sinus Syndrome

A spectrum of cardiac anomalies in which part or all of the

common wall between the coronary sinus and left atrium is

absent

Operation is advisable with diagnosis when

  • With persistent Lt SVC

    Arterial desaturation

    Risk of cerebral embolism

    Good results of operation

  • Without persistent Lt SVC(Coronary sinus ASD)

    Same as for other type ASD

  • Associated with other major cardiac anomalies

    Clear indication for operation


Total anomalous pulmonary venous connection

Total Anomalous Pulmonary Venous Connection

These are no direct connection between any

pulmonary vein and the LA. But rather, all the

pulmonary veins connect to the RA or one of its

tributaries

Dx is an indication of operation

  • Immediate repair with Dx in any ill neonate :

    Preop preparation is not needed

  • Repair should be done nearly always before 6 mo

  • Dx at 6-12 mo : prompt repair is indicated


Ventricular septal defect

Ventricular Septal Defect

  • A hole (or multiple holes) between Lt & Rt ventricle

  • Symptomatic large VSD : an indication of operation

  • Before 3 mo : indicated in large VSDs with CHF or respiratory symptoms

  • Moderate sized VSDs (Qp/Qs < 3.0) with few symptoms : observation during infancy

  • Small VSDs (Qp/Qs < 1.5) :

    not indicated, risk of bacterial endocarditis

  • Subarterial type : early repair is indicated before childhood


Atrioventricular septal defect

Atrioventricular Septal Defect

  • Abnormalities of atrioventricular valve form & function and interatrial & interventricular communication from maldevelopment of the endocardial cushions

  • Presence of AVSD : indicated with Dx

    • Partial AVSD : 1-2 years of age except CHF or growth failure

    • Complete AVSD with good condition : 3-6 mo

    • Complete AVSD with refractory CHF or respiratory Sx : indicated promptly

    • Development of pulmonary vascular obstructive disease : not indicated


Congenital aortic stenosis

Congenital Aortic Stenosis

  • The various forms of LVOTO occur in combination with other cardiac lesions (IAA, COA, MV anomalies, LV hypoplasia) and obstructive types are supravalvular, valvular, subvalvular, intraventricular

  • Critical AS in neonates : urgent (severe CHF, LV

    dilatation, hypertrophy)

  • Infants and children

    Pressure gradient > 75mmHg

    Sx of angina, syncope, exercise intolerance, LVH,

    pressure gradient > 50mmHg

    Pressure gradient over 40mmHg in subvalvular lesion

    to prevent progression


Aortopulmonary window

Aortopulmonary Window

  • Abnormal development of aortopulmonary septum caused by incomplete formation of the right and left conotruncal ridges.

  • Symptomatic AP window is an indication

    • Symptomatic infants : indicated with Dx

    • Repair is advised before 3 mo of age (size, increased shunt, pulmonary hypertension)

    • Old children should be operated on unless PVR render them inoperable


Aneurysm of sinus of valsalva

Aneurysm of Sinus of Valsalva

  • Thin walled, tubular outpouchings, nearly always Rt sinus or adjacent half of the noncoronary sinus and with an entirely intracardiac course, that may rupture into the right (rarely left) heart chamber to form a fistula

  • Ruptured sinus of Valsalva : indicated promptly because of abrupt development of CHF

  • With VSD or VSD+AI : prompt repair is indicated

  • Large aneurysms producing hemodynamic derangement : indicated

  • Small and moderate sized aneurysm without symptom : not indicated


Cor triatriatum

Cor Triatriatum

  • A rare congenital cardiac anomaly in which pulmonary veins typically enter a proximal left atrial chamber separated from the distal left atrial chamber by a diaphragm in thich there are one or more restrictive ostia (sinister, dexter)

  • Indication for operation

  • Restrictive aperture in the partition is an urgent indication

  • Symptoms usually develop early, and operation is necessary in the 1st year of life

  • Life expectancy after repair in infancy is excellent


Congenital ms and mr

Congenital MS and MR

  • A developmental malformation of one or more of the components of MV apparatus, including LA wall adjacent insufficiency or a combined lesion

  • Infancy

  • Mild and moderate Sx without MVR :

  • Supravalvular ring, commmissural fusion

  • Other circumstances : only for infants with heart failure

  • Childhood

  • Considerations for operation are similar CHF

    Severe pulmonary HT

  • MVR should be withheld whenever possible


Ebsteins anomaly

Ebsteins anomaly

  • A congenital defect of tricuspid valve in which the origin of septal and posterior leaflets or both are displaced downward into the right ventricle and the leaflets are variably deformed

  • Symptomatic Ebstein’s anomaly is an indication

    • Neonates presenting in extremes :

      Starnes procedure in first week

    • Valve repair and ASD closure :

      with important TR

      moderate and severe cyanosis

    • WPW syndromes :

      ablation of accessory conduction pathway


Pulmonary stenosis

Pulmonary Stenosis

  • A form of RV outflow obstruction in which stenosis is usually valvar or both valvar & infundibular or only infundibular

    • Critical PS in neonate : indicated with Dx

      Percutaneous balloon valvotomy

      Valvotomy with CPB

      Transannular RVOT patch widening

      Valvotomy with inflow occlusion technique

    • PS in infants and children : indicated with Sx & Pr gradient over 50mmHg

    • Surgical treatment is not indicated with mild stenosis


Pa with intact ventricular septum

PA with Intact Ventricular septum

  • A cardiac anomaly in which the pulmonary valve is atretic, coexisting with variable degree of right ventricle and tricuspid valve hypoplasia

  • Dx is an indication of operation

    • Size of the TV : Z-value of the tricuspid valve

      < -4 --- Systemic-pulmonary artery shunt

      -2~-4 --- RVOT patch + shunt

      > -2 --- RVOT patch

    • Evaluation after 6-12 mo after initial procedure :

      Two ventricle repair

      One and half ventricle repair

      Fontan procedure


Tetralogy of fallot

Tetralogy of Fallot

  • Characterized by underdevelopment of RV infundibulum with anterior and left ward displacement

  • Dx is an indication of operation

    • Symptomatic complicated in early life :

      Early total correction or

      Shunt (1-2 mo) and total correction (1 year)

    • Asymptomatic uncomplicated :

      Total correction at 3-24 mo

    • Multiple VSDs, LAD from RCA :

      Initial shunt and total correction


Pulmonary atresia with vsd

Pulmonary Atresia with VSD

  • These are no luminal continuity between RV & pulmonary trunk among the group of TOF. It is usually congenital, but may be acquired.

  • Dx is an indication of operation

    • Confluent and normally distributing PAs:

      Complete repair in early life

      Palliation and repair (3-5 year) with conduit

    • Confluent PAs distributing to the major segments :

      Pul. Segments > 15 --- need not unifocalization

      repair with conduit in 3-5 years

    • Nonconfluent PAs distributing to the minor segment :

      Mmultistage operation with unifocalization

      Palliative shunt only


Double outlet right ventricle

Double Outlet Right Ventricle

  • A congenital cardiac anomalies which both great arteries rise wholly or in large part from the RV. It is, then, a type of ventriculoarterial connection.

  • Dx is an indication of operation

    • Simple DORV with subaortic VSD : repair by 6 mo

      with PS --- repair like TOF

    • DORV with subpulmonic VSD (Taussig-Bing heart) :

      arterial switch operation within 1 mo

      with PS --- REV or Rastelli operation at 3-5 years

    • DORV with noncommitted VSD :

      VSD enlargement and intraventricular tunnel

      Fontan operation


Transposition of great arteries

Transposition of Great Arteries

  • A cardiac anomaly in which the Ao arises entirely or in large part from the RV, and PA from LV (atrioventricular concordant connection and ventriculoarterial discordant connection)

  • Simple TGA in neonate :

    arterial switch operation within 1 mo

  • Simple TGA beyond 30 days :

    rapid two-stage operation

    atrial switch operation (Mustard, Senning)

  • TGA with VSD :

    arterial switch operation as early

  • TGA with VSD and LVOTO

    Lecompte operation at 6-18 mo

    Rastelli or Lecompte operation at 3-5 years


Tricuspid atresia

Tricuspid Atresia

  • A cardiac anomaly in which RV fails to open into a

    ventricle through a AV valve. There is thus a

    univentricular AV connection

  • PVR is an important indicator

    > 4 unit -- contraindicaton

    2-4 unit -- BCPS

    < 2 unit -- Fontan operation

    • Symptomatic in early life

      early shunt or PAB

      BCPS or hemi-Fontan at 6-12 mo

      Fontan at 12-24 mo

    • Nonsymptomatic

      Fontan candidate : 12-30 mo


Double inlet ventricle

Double Inlet Ventricle

  • A cardiac anomaly in which both atria connect to only one ventricular chamber by either two separate AV valve or a common AV valve

  • Dx is an indication of operation

    • Septation : 1-2 years

      enlarged dominant ventricle

      two competent nonstenotic AV valve

      no pulmonary or systemic outflow obstruction

    • Fontan operation : 1-2 years

      < 3-5 mo--- systemic outflow obstruction

      6 - 12 mo --- BCPS

      1 – 2 years --- Fontan operation

    • Cardiac transplantation


Interrupted aortic arch

Interrupted Aortic Arch

  • Complete luminal and anatomic discontinuity between two segments of the aortic arch, and generalized narrowing of LVOT, posterior malalignment, muscle of Moulaert, small aortic annulus, aortic hypoplasia

  • Dx is an indication of operation

    • Coexisting cardiac anomaly : not contraindication

    • One-stage repair : preferred

    • Two-stage repair : in complicated intracardiac

      anomalies

    • Single ventricle associated : alternative plan


Hypoplastic left heart syndrome

Hypoplastic Left Heart Syndrome

  • A wide spectrum of cardiac anomaly with various degree of hypoplasia of the structure of the left side of the heart

  • Dx is an indication of operation

    • First stage palliation : 1-30days

      Norwood operation

    • Second stage palliation : 6-12 mo

      BCPS

      Hemi-Fontan

    • Third stage correction : 18-24 mo

      Completion Fontan

    • Cardiac transplantation :

      Aortic diameter < 2.5 mm


Truncus arteriosus

Truncus Arteriosus

  • A cardiac anomaly in which one great artery, arising from the base of the heart by way of a truncal valve, PAs proximal to the origin of the brachiocephalic branches.

  • Presence of truncus arteriosus : an absolute

    surgical indication.

  • Neonatal repair is recommended :

    Homograft interposition

    Prosthetic valve conduit

    Autologous tissue reconstruction

  • Repair should be done before 6 mo

  • Pulmonary vascular obstructive disease :

    contraindication


Congenitally corrected tga

Congenitally Corrected TGA

  • A cardiac anomaly with ventriculoarterial discordant connection & atrioventricular discordant connection. The circulatory pathways are therefore in series

  • The presence of CCTGA per se is not an indication.

  • With VSD : indications for VSD

  • With VSD + PS : indications for TOF

  • Isolated TR : indication for MR

  • With complete heart block : pacing

  • Fontan procedure indicated :

    straddling tricuspid valve

    complete AVSD

    left sided tricuspid valve incompetence

  • Double Switch operation : anatomic correction


Anatomically corrected malposition of great arteries

Anatomically Corrected Malposition of Great Arteries

  • A cardiac anomaly in the position of the great arteries and not in cardiac connection. The LV probably always exhibits a well formed subaortic conus and the RV has less well developed infundibulum than normal

  • Diagnosis is not an indication for operation

  • Coexisting cardiac anomalies are indications

    Large VSD always present

    Pulmonary stenosis is usual

    Subaortic stenosis may occur

    Tricuspid atresia or TV hypoplasia in half


Double outlet left ventricle

Double Outlet Left Ventricle

  • A cardiac anomaly in which both great arteries arise from the left ventricle with nearly always with large VSD, and frequent occurrence of PS.

  • Dx is an indication for op.

  • Without PS :

    Performed in the 1st 6mo of life

    Banding and delayed repair

    Intracardiac baffling

    Conduit repair

  • With PS :

    Classic shunt before the age of 2 years

    Simple intraventricular repair

    LeCompte procedure in infancy

    Conduit repair in childhood


Coronary arteriovenous fistula

Coronary Arteriovenous Fistula

  • Direct communication between coronary artery and lumen of any one of cardiac chamber, or coronary sinus, or its tributary veins, or SVC, PAs, or Pulmonary veins close to the heart

  • Indicated unless the shunt is small (Qp/Qs<1.3)

    Increase in size

    Sx and heart failure

    SBE

    Low probability of spontaneous closure

    Safety and efficacy of operation

  • Techniques

    • Suture ligation without CPB

    • Closure of transcoronary artery with CPB

    • Transcardiac chamber closure with CPB


Anomalous lca from the pa

Anomalous LCA From the PA

  • Whole of the left main or LAD, or circumflex branch connects anomalously to main pulmonary artery or rarely from proximal RPA. Very rarely, both coronary arteries connect to the pulmonary artery by a single trunk.

  • Urgent operation is indicated in infancy. The condition is an also indication for op in older patient as well.

    • Construction of a two coronary system

      LCA transfer

      CABG

      Subclavian-left coronary anastomosis

      Tunnel operation

    • Ligation of LCA


Atrial isomerism

Atrial Isomerism

  • A condition which the right sided and left sided atria, normally morphologically different, are morphologically similar.

  • Surgical treatment is indicated with coexisting anomaly, not by the atrial isomerism.

  • Intraventricular complex repair

  • Complex atrial baffling

  • Fontan type repair

  • Palliative operation


Cardiac transplantation

Cardiac Transplantation

  • Indications

    Cardiac diseases that has a poor prognosis for short-term survival(<1 year) and that is not treatable by conventional therapy

  • Contraindications

  • Severe and life-limiting coexisting medical problems

  • Active bacterial or viral infection

  • Psychosocial family situation

  • Presence of severely elevated PVR (>8 Wood Units)

  • Immunologic status of the recipient panel-reactive antibody (PRA) > 25%


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