Surgical perspectives on Surgical perspectives on Congenital Heart Congenital Heart

DiseaseDiseaseCritical Care Update Critical Care Update

May 2010May 2010

Dr. Pranav S KDr. Pranav S K

Sri Sathya Sai Institute of Sri Sathya Sai Institute of Higher Medical SciencesHigher Medical Sciences

BangaloreBangalore

Humble Pranams at the Lotus Feet of Humble Pranams at the Lotus Feet of Bhagwan Bhagwan

Two major issuesTwo major issues

Cardiac Surgeon and Post cardiac Cardiac Surgeon and Post cardiac surgery Critical Caresurgery Critical Care

Echocardiography and Surgeon and Echocardiography and Surgeon and critical carecritical care

Why does an intensivist need Why does an intensivist need a “surgical perspective”?a “surgical perspective”?

One would like to know what kind of a One would like to know what kind of a deal one is gettingdeal one is getting

There are things that surgeons can There are things that surgeons can correctcorrect

many they cannotmany they cannotsome they may misssome they may misssome they think they corrected but some they think they corrected but

nature intended otherwisenature intended otherwiseAnd many things that surgeons can And many things that surgeons can

damagedamage

The blood brain barrier

BASIC SURGICAL BASIC SURGICAL PRINCIPLEPRINCIPLE

Blue Blood to Pulmonary Blue Blood to Pulmonary and Red blood to Systemic and Red blood to Systemic

without any mixing and without any mixing and without any obstructionwithout any obstruction

Glorified Plumbers ?

What inputs can a surgeon What inputs can a surgeon provide ?provide ?

Curative vs PalliativeCurative vs PalliativeBiventricular vs Univentricular Biventricular vs Univentricular

(vs one and a half ventricular repair)(vs one and a half ventricular repair)Single Stage vs Staged ProcedureSingle Stage vs Staged ProcedureOpen or Closed (If Open then TCA +/-)Open or Closed (If Open then TCA +/-)Surgical Approach – Sternotomy, Surgical Approach – Sternotomy,

Thoracotomy, Minimally invasive. Thoracotomy, Minimally invasive. “Open chest”“Open chest”

OTHER INPUTSOTHER INPUTS

Events prior to going on CPBEvents prior to going on CPBRelevant intraoperative findingsRelevant intraoperative findingsOperative details (in brief), with diagram Operative details (in brief), with diagram Off clamp – Rhythm, PacingOff clamp – Rhythm, PacingEvents coming off CPB, inotropes.Events coming off CPB, inotropes.What to look for from a surgical What to look for from a surgical

standpointstandpoint

e.g. effusions after Fontane.g. effusions after FontanHemodynamic targets Hemodynamic targets

Getting the full pictureGetting the full picturePre Op AssessmentPre Op Assessment

Anatomy – Review clinical data, ECG, CXR, Anatomy – Review clinical data, ECG, CXR, Echo, Cath, CT/MRI, hematology etc Echo, Cath, CT/MRI, hematology etc

Physiology – Physiology – VSD VSD TET TET TRANSPOSITIONTRANSPOSITIONSINGLE VENTRICLESINGLE VENTRICLE

Intraop AssessmentIntraop AssessmentAnesthesia management, perfusion charts.Anesthesia management, perfusion charts.Intraop TEE, Epicardial echoIntraop TEE, Epicardial echo

Post Cardiac Surgical patient Post Cardiac Surgical patient

CPB related changesCPB related changesChanges related to cardiac surgery in generalChanges related to cardiac surgery in generalChanges specific to the Defect & the SurgeryChanges specific to the Defect & the Surgery

BLOOD PRESSUREBLOOD PRESSUREBREATHINGBREATHINGBEATSBEATSBLEEDINGBLEEDINGBRAINBRAIN

ICUICU TROUBLESHOOTINGTROUBLESHOOTING

PreloadPreloadLV ContractilityLV Contractility(Afterload)(Afterload)Tamponade – Tamponade – IS A CLINICAL DIAGNOSISIS A CLINICAL DIAGNOSISResidual/ Additional/New LesionsResidual/ Additional/New Lesions

Residual VSD, PFO, valve leaks, Residual VSD, PFO, valve leaks, residual outflow tract obstruction, residual outflow tract obstruction,

Baffle obstruction Baffle obstruction Pulmonary Hypertension – IVS position, RVSPPulmonary Hypertension – IVS position, RVSPRV function, Restrictive RV physiologyRV function, Restrictive RV physiology

When does Echo come in? When does Echo come in? Low Cardiac OutputLow Cardiac Output

PFO / Fenestration - RT TO LT SHUNTPFO / Fenestration - RT TO LT SHUNT

Coronary sinus committed to LACoronary sinus committed to LA

BT shunts –BT shunts – Inadequate shunt/ Blocked Inadequate shunt/ Blocked shuntshunt

Overshunting leading to pul Overshunting leading to pul hem hem

Tight PA Band Tight PA Band

Pulmonary Venous Obstruction after Pulmonary Venous Obstruction after TAPVC repair, PAPVC repairTAPVC repair, PAPVC repair

Streaming issues (Contrast Echo)Streaming issues (Contrast Echo)

Echo in Post op Pediatric Cardiac Echo in Post op Pediatric Cardiac SurgerySurgery

Low PaO2Low PaO2

Appearance or disappearance of murmurs Appearance or disappearance of murmurs

Recurrence of MR after CAVC repair Recurrence of MR after CAVC repair

Chordal rupture after OMV Chordal rupture after OMV

Loosening of PA Band or LigaturesLoosening of PA Band or Ligatures

Occlusion of conduits, mech valves, Occlusion of conduits, mech valves, coronaries.coronaries.

Paravalvar leaksParavalvar leaks

Large Effusions - Pleural, Pericardial, PeritonealLarge Effusions - Pleural, Pericardial, Peritoneal

Unusual Findings Unusual Findings

Pulse discrepancy after PDA ligation.Pulse discrepancy after PDA ligation.

Oligemic left lung field after PDA ligation.Oligemic left lung field after PDA ligation.

Echo in Post op Pediatric Cardiac Echo in Post op Pediatric Cardiac SurgerySurgery

ALTERATION IN CLINICAL CONDITION ALTERATION IN CLINICAL CONDITION

Mild COA s/p PDA ligation Mild COA s/p PDA ligation

S/p PDA ligationS/p PDA ligation

Main Limitation of Echo - viewsMain Limitation of Echo - views

Getting the views with TTE Getting the views with TTE

interference due to air, dressings, interference due to air, dressings, drainsdrains

Views are often better in childrenViews are often better in childrenThe view does improve with timeThe view does improve with time If necessary, Trans esophageal echo If necessary, Trans esophageal echo

is the choice, but size of the probe is the choice, but size of the probe may be limiting in children.may be limiting in children.

3 D echo LA view of an 3 D echo LA view of an OSASDOSASD

ASDASDWhat could possibly go wrong – What could possibly go wrong –

No ASD? Pectus No ASD? Pectus

Pulmonary vein orifice/ CS mistaken for Pulmonary vein orifice/ CS mistaken for ASDASD

Coronary sinus type ASD with partially or Coronary sinus type ASD with partially or completely unroofed CS may be missedcompletely unroofed CS may be missed

High PAPVC may be missedHigh PAPVC may be missed

most mortalities in history of ASD surgery– most mortalities in history of ASD surgery– Cor triatriatum.Cor triatriatum.

False drop outFalse drop out

false neg a4c.avi

Absent RSVC, situs solitus, Absent RSVC, situs solitus, OSASDOSASD

Echo & Post op issues in ASDEcho & Post op issues in ASD

RA and RV may look baggy, CVP is RA and RV may look baggy, CVP is usually low. Do not chase the CVP, if BP is usually low. Do not chase the CVP, if BP is alright. alright.

Desaturation – IVC to LA Desaturation – IVC to LA Baffle related problems – Pulmonary vein Baffle related problems – Pulmonary vein

or systemic vein obstructionor systemic vein obstructionMR after Partial AV canal repairMR after Partial AV canal repairRecurrent pericardial effusions Recurrent pericardial effusions

Posterior ASDPosterior ASD

VSD - PhysiologyVSD - Physiology

Oxygen rich blood flows across the VSD from the left ventricle to the right ventricle and out the Pulmonary Artery Resulting in increased Pulmonary Blood Flow

VSD typesVSD types

VSD - PHYSIOLOGYVSD - PHYSIOLOGYShunts in SystoleShunts in SystoleShunt depends on size of the VSD and the Shunt depends on size of the VSD and the

SVR and PVR (Especially so if the VSD is SVR and PVR (Especially so if the VSD is nonrestrictive). Cath data often gives a nonrestrictive). Cath data often gives a clueclue

Use Oxygen and IV fluids with cautionUse Oxygen and IV fluids with caution

Congestive Heart Failure in infancy, Congestive Heart Failure in infancy, failure to thrive. failure to thrive.

Recurrent LRTIRecurrent LRTIEisenmengerEisenmengerAortic regurgitationAortic regurgitation

VSD - RepairedVSD - Repaired

Patch sewn across VSD

Echo in Post op issuesEcho in Post op issues

Residual VSDResidual VSDAdditional VSDAdditional VSDPulmonary hypertensionPulmonary hypertensionTRTRARARRVOTORVOTO

AVSD - AnatomyAVSD - Anatomy

AVSD - RepairedAVSD - Repaired

Echo after AV Canal repairEcho after AV Canal repair

Residual VSD/ASD/LV-RA shuntResidual VSD/ASD/LV-RA shuntLeft AV valve stenosis or Left AV valve stenosis or

regurgitationregurgitationRight AV valve stenosis or Right AV valve stenosis or

regurgitationregurgitationPulmonary hypertensionPulmonary hypertensionLVOTOLVOTOAdequacy of ventriclesAdequacy of ventricles

PDA - PhysiologyPDA - Physiology

Blood flows from the Aorta across the duct into the Pulmonary Arteries resulting in increased Pulmonary Blood Flow

PDA - RepairedPDA - Repaired

PDA Ligated via Left sided Thoracotomy

What could go wrongWhat could go wrong

Residual PDAResidual PDALigated something else instead –Ligated something else instead –

Aortic isthmus (femoral art line)Aortic isthmus (femoral art line)

LPA (ETCO2 will fall)LPA (ETCO2 will fall)Residual COAResidual COADuctus tearDuctus tearLung injuryLung injuryRecurrent laryngeal nerve injuryRecurrent laryngeal nerve injuryDelayed – ductal aneurysmDelayed – ductal aneurysm

Tetralogy of Fallot - AnatomyTetralogy of Fallot - Anatomy

1. VSD2. Subpulmonary Stenosis

3. Aortic Override

4. Right Ventricular Hypertrophy

Tetralogy of Fallot - RepairedTetralogy of Fallot - Repaired

VSD Closed with Patch

Infundibular Stenosis resected

Tetralogy of Fallot - RepairedTetralogy of Fallot - Repaired

Echo after Tet repairEcho after Tet repairResidual RVOTOResidual RVOTOResidual VSDResidual VSDRV dysfunctionRV dysfunctionRestrictive RV physiologyRestrictive RV physiologyTR, PRTR, PRTamponadeTamponadeDesaturation (PFO Rt to Lt)Desaturation (PFO Rt to Lt)Coronary crossing RVOTCoronary crossing RVOTARAR

TGA - AnatomyTGA - Anatomy

TGA - PhysiologyTGA - Physiology

Two Circuits in parallel, the only mixing occurs at the level of the duct, patent foramen ovale or VSD if present

Arterial Switch & coronary Arterial Switch & coronary transfertransfer

TGA – The ‘French’ TGA – The ‘French’ ManoeuvreManoeuvre

To concludeTo conclude

Surgical input is a must in Post op Surgical input is a must in Post op ICU management of the cardiac ICU management of the cardiac surgical patientsurgical patient

Echocardiography is our “Apat Echocardiography is our “Apat bandhava” and a very important bandhava” and a very important member of the ICU team. member of the ICU team.