CHD Surgery New

8/6/2019 CHD Surgery New

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CONGENITAL

HEART

DISEASE

Prepared By ,

Sonia Bhatia(F.Y. M.P.T)


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Introduction

The primitive vascular tube apparent by the third weekof fetal life.

Over the next weeks it folds in on itself.

By 12 weeks it has fully developed.


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Classification:

Acyanotic congenital heart disease.

Cyanotic congenital heart disease.


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Acyanotic congenital heart diseases

Patent ductus arteriosus:

This anomaly 5 to 10 percent of congenital heart disease.


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Etiology :

Apatent ductus arteriosus can be idiopathic.

Some common contributing factors in humans include:

Preterm Birth

Congenital Rubella Syndrome

Down Syndrome


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Pathol

ogy:As the higher pressure in the aorta then in the pulmonary artery

Blood flow from aorta to pulmonary artery

Pulmonary blood flow increase to the lungs, the pulmonaryvessels dilated

More blood to left side of heart

Left ventricular hypertrophy


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Signs and symptoms : Tachycardia Shortness of breath

Continuous machine-like murmur

Enlarged heart Left subclavicular thrill

Bounding pulse

Investigation: Electrocardiogram show left ventricular hypertrophy.

Cardiac catherisation

A

ortography


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Operation:U

sually carried out in babies over 2-3 years of age.

Technique:

Operation performed through a left posterolateral thoracotomy through the 5th

intercostals space.

Lung retracted

Mediastinal pleura incised over aortic arch

So ductus arterious cleared

Ligation of patent ductus with multiple non-absorbable ligatures

Two transfixation ligatures one on either end of ductus and two in middleportion of the ductus.

Temporary aortic shunt, usually left atriofemoral by pass used totemporary occlusion of aorta above or below the ductus.


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COARCTATAIONOF AORTA5% common of congenital heart disease.

Obstruction of the aorta in the region of the ductus arteriosus orligamentum arteriosum just distal to the left subclavian artery.


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There are three types:Preductal coarctation:

The narrowing proximal to the ductus arteriosus.

Ductal coarctation: The narrowing occurs at the insertion of the ductus

arteriosus. This kind usually appears when the ductusarteriosus closes.

Postductal coarctation:

The narrowing is distal to the insertion of the ductusarteriosus.


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Clinical features:

ypertension

Hypotension

Investigation:

Chest radiographs

Cardiac catheterisation

Aortography


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TREATMENTOperative Technique:

The coarctation of aorta is excised and end-end anastomosis of theaorta is performed usually with a graft.

Left posterolateral thoracotomy through 4th intercostal space.

Mediastinal pleura incised, after which vagus nerve is retractedmedially.

Aorta mobilized both above and below constriction take care notdamage the intercostal vessels.

Proximal and distal aorta occluded with vascular clamps.


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Coarctation of aorta excised

End to end anastomosis possible

Continuous sutures with prolene

After anastomosis, blood pressure measured proximal and distal toanastomosis

Difference blood pressure more than 4 to 5 mm Hg

Dacron patch inserted through short anterior arteriotomy

Widen the lumen of the aorta

Postoperatively antibiotics given for 3 to 4 days

Patients are discharge in 7 to 10 days


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ATRIAL SEPTAL DEFECT

This defects allows blood to flow from left to right atrium, so that rightside of heart and lungs become overfilled, whereas left side heartreceives less blood.

Three types:1. Fossa ovalis defect (Secundum defect): Commonest and lies in centre of the septum. Failure of development of septum secundum.

Symptoms: FatiguePalpitationExertional dyspnoea

Signs: Soft systolic murmur sound.


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Treatment:Incision:

Median sternotomy through 4th intercostal Space.

Direct suturing and closure of defect by continuoussuture with prolene.

If direct suturing is not possible, prosthetic patch of

knitted dacron may inserted with help of heart-lungmachine.


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Atrioventricular septal defect (ostium primum defect):

4 to 5% of patients with atrial septal defect, associated withincomplete formation of mitral and tricuspid valves.

Treatment:

Incision.Operative procedure: Operative is usually between 4 to 6 years of age. Operation performed with help of heart-lung machine. Initially cleft in mitral valve is closed with interrupted sutures

placed from ventricular septum out to free margin of mitralorifice.

After cleft repair, septal defect repaired with patch ofpericardium inserted with interrupted sutures.


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Anoma

lous drainage of pu

lmonary veins:

Right pulmonary veins usually enter the superior vena cava inferior topoint of entry of azygos vein or enter into the right atrium or intoinferior vena cava.

Left pulmonary vein may also enter the superior vena cava.

Treatment:

Anomalous veins can be corrected by insertion of prosthetic patch

Defect is closed

Pulmonary veins are enter the left atrium


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VENTR

ICULAR S

EPTAL

DE

FEC

TCommon 20 to 30 % .Defect situated in muscular or membranous portions of theseptum.

Septum defect varies from 3 mm to more than 3 cm in size.Clinical features:

Large septal defect-Dyspnoea on exertionHaemoptysis

Physical examination:

Loud pansystolic murmur in 3rd and 4th intercostal space.Thrill is palpable.Rales due to pulmonary congestion.


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Treatment :Operation :

Technique:

Operation performed through a median sternotomy with

help of extracorporeal circulation

Longitudinal ventriculotomy performed usually ininfundibular part of right Ventricle and near anterior

descending coronary artery

Defect usually closed with an oval patch of knitted dacron bymattress sutures posteriorly and continuous suture

anteriorly


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Pulmonary Stenosis:

In this incomplete obstruction to the flow from the right ventricle.

Haemodynamics:

Pulmonary circulation is decreased

Work of right ventricle increased Right ventricular hypertrophy

Diminished cardiac output

Symptoms:

Exertional dyspnoea Fatigue

Systemic venous congestion

Hypoxaemia

Cardiac failure


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Treatment :Incision :

Median sternotomy

Open procedure:

Valve exposed via anterior aspect of pulmonary artery thecommissures are cut.

If annulus is constricted it is cut through vertically anddacron inserted.

It may be necessary to replace the valve.


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Aortic Stenosis :

Left ventricular outflow obstruction may be caused atthree levels :

Valvular Subvalvular

Supravalvular

The patients with valvular stenosis do notdevelop symptoms until the valve calcified around theage 40-50.


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Haemodynamics:The narrowed valve orifice subjects the left ventricle to apressure overload.

Left ventricle hypertrophy develops.

Symptoms :

Mild asymptomatic

Severe FatigueSyncopeDyspnoea


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Treatment :

Incision : Amedian sternotomy.Open procedures :

Valvular Stenosis :

Valvotomy is performed by entering the ascending aorta and

incising the commissures.

Subvalvular Stenosis :

It may approached through a low aortic incision and

through valvular excision will be undertaken.Supravalvular Stenosis :

Relieved by suturing an elliptical dacron into the verticalincision through the constricted portion of aorta.


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Physiotherapy Treatment :

Pre-operative Treatment :

Infants with cardiac problem have pulmonary hypertension

associated with excessive secretion leading to repeated chestinfection.

So chest physiotherapy important that the lung field are clear aspossible prior to the surgery.

PercussionShaking and vibrationsPostural drainage


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Post-operative Treatment :

Chest PT will begin when patients condition stabilized.

In some unit treatment will be on the day of operation , in others , dayafter.

Depends on the type of operation the patient may or may not beventilated.

Patients should be assessed and physiotherapy given as necessary.

Carefully watch the patients vital signs at all times.

Patients have small amount of secretions easily removed by suctionalone.

Early mobilization is important to stimulate deep breathing andcoughing.

Nasopharyngeal suction may be used in infants and children.


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References :

1.) Textbook of surgery by, S.Das , 5th Edition.

2.) Bailey & LovesShort practice of surgery , 22nd Edition.

3.) DavidsonsPrinciples & practice of medicine , 20th Edition.

4.) Cashs Textbook ofChest , Heart and Vascular Disorders for Physiotherapists ,

4th Edition.


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