Surgical Indication AtriaSurgical Indication Atrial Septal Defectl Septal Defect

Surgical Indication AtriaSurgical Indication Atrial Septal Defectl Septal Defect

Anatomical Indications• Uncomplicated ASD• PAPVC (partial anomalous

pulmonary venous connection, PAPVR) with evidence of RV volume overload

Hemodynamic Indications

• Pulmonary-systemic blood flow ratio (Qp/Qs) ≧2

• uncomplicated anomaly Qp/Qs≧1.5– Exception: Scimitar syndrome (=PAPVR)

with severe hypoplasia of the right lung and a Qp/Qs<2 (However, surgery may be needed because of complications of bronchopulmonary sequestration)

PAPVC• Isolated PAPVC of a part of one lung

without an ASD is not an indication when the Qp/Qs<1.8

• Isolated PAPVC of a whole lung is an indication (should the normal lung be importantly compromised potentially fatal anoxia occurs)

Age• Age < 5y/o (1~2y/o can be

considered for deleterious effects of long- termed RV volume overload), but diagnosis was often made later in life

• Age is not an contraindication (very young or very old)

Pulmonary vascular resistance

• Pulmonary vascular resistance=8~12 U·m2 at rest and cannot decrease to less than 7 under pulmonary vasodilator were surgical contraindication (Qp/Qs<1.5 with elevated pulmonary artery pressure is often, sometimes present with Qp/Qs=2)

Associated TR, MR• Associated TR and/or MR (present particula

rly in older patients) is not a contraindication to operation– Grading of MR angiography is difficult (ASD pres

ent and major runoff from left to right antrium) and regurgitation became important when ASD closed

– Moderate MR is usually an indication for MVR

Summary• Pulmonary-systemic blood flow ratio

(Qp/Qs) ≧2• Pulmonary vascular resistance=8~12

U·m2 at rest and cannot decrease to less than 7 under pulmonary vasodilator were surgical contraindication

Ventricular Septal DefecVentricular Septal Defectt

Ventricular Septal DefecVentricular Septal Defectt

• A schematic presentation of the three main anatomic components of the interventricular septum as seen from the morphologic right ventricle (A) and the morphologic left ventricle (B). Component 1: septum of the atrioventricular canal; Component 2: septum of the muscular septum; and Component 3: parietal band or distal conal septum.

• Planes of Doppler interrogation for different ventricular septal defects as seen in parasternal short axis.

Surgical Indications: Symptom

• Approximately 30% of infants with severe symptoms form VSDs requires operation within the first year of life because of intractable congestive heart failure or, more commonly, failure to thrive– Symptomatic: Qp/Qs>1.5, pulmonary artery sys

tolic pressure > 50mmHg, increased LV and LA size, or LV dysfunction

• The majority of membranous and muscular VSDs tend to close spontaneously. – Surgical closure early in life is indicated

only if the infant has failed aggressive medical management with digitalis and diuretics

Asymptomatic infant with persistent VSD

• Cardiac catheterization should be performed at the end of the first year of life. If pulmonary artery pressure > ½ systemic pressure, closure should be performed.

Hemodynamic Indication

• Qp/Qs≧1.5• Pulmonary artery systolic pressure

> 50mmHg

Pulmonary Vascular Resistance

• If pulmonary arteriolar resistance is less than 7 Wood units, closure can be safely undertaken

• <1y/o, with VSD, pulmonary-to-systemic vascular resistance >0.7 are still considered surgical candidates – because the likehood that elevated pulmonary

vascular resistance reflects irreversible pulmonary vascular change within the first year of life is extremely small.

Aortic Incompetence• VSD with first showed the development of the mur

mur of aortic incompetence (AI), repair of VSD should be promptly accomplished while the AI still mild

• Cusp prolapse was showed in association with any juxtaaortic VSD, early repair is also indicated

• Juxtaarterial VSDs and right ventricular outflow juxtaaortic VSDs of significant size, even without cusp prolapse should be closed before 5y/o, to prevent cusp prolapse

Aortic Incompetence• When moderate or severe AI and cusp prola

pse were noted, operation should be undertaken promptly. It should be done before 10y/o – Reconstruction of the valve is usually possible

when OP is done during the first decade of life– UAB: the average age of the patients requiring r

eplacement was 19.5 years, compared with 12.1 years for the remainder of the group

Aortic Incompetence• When no cusp prolpase and severe AI with minima

l enlargement of the sinuses is present, a bicuspid valve is probably present, and valve replacement may be required. (It means AR was not induced by VSD) VSD repair should be postponed until significant symptoms develop or LV enlargement itself indicates the need of for operation

• When the operation is delayed until adult life, aortic valve replacement is usually required.

Summary (1)• Surgical indications

– Qp/Qs≧1.5– Pulmonary artery systolic pressure > 50

mmHg– pulmonary arteriolar resistance < 7 Woo

d units– VSD related AI (RCC prolapse, NCC prola

pse)

Summary (2)• Membranous and muscular type

VSD may close spontaneously

References1. Kirlin Cardiac Surgery2. Zipes: Braunwald’s Heart Diseae: A Text

book of Cardiovascular Medicine3. Park: Pediatric Cardiology for Practitioner

s4. Cardiac surgery of the neonate and infant