Sri Sathya Sai Institute of Higher Medical Sciences Surgical perspectives on Congenital Heart Disease Critical Care Update May 2010 Dr. Pranav S K Sri Sathya Sai Institute of Higher Medical Sciences Bangalore

Humble Pranams at the Lotus Feet of Bhagwan

Two major issues Cardiac Surgeon and Post cardiac surgery Critical Care Echocardiography and Surgeon and critical care

Why does an intensivist need a “surgical perspective”? One would like to know what kind of a deal one is getting There are things that surgeons can correct many they cannot some they may miss some they think they corrected but nature intended otherwise And many things that surgeons can damage

The blood brain barrier

BASIC SURGICAL PRINCIPLE Blue Blood to Pulmonary and Red blood to Systemic without any mixing and without any obstruction Glorified Plumbers ?

What inputs can a surgeon provide ? Curative vs Palliative Biventricular vs Univentricular (vs one and a half ventricular repair) Single Stage vs Staged Procedure Open or Closed (If Open then TCA +/-) Surgical Approach – Sternotomy, Thoracotomy, Minimally invasive. “Open chest”

OTHER INPUTS Events prior to going on CPB Relevant intraoperative findings Operative details (in brief), with diagram Off clamp – Rhythm, Pacing Events coming off CPB, inotropes. What to look for from a surgical standpoint e.g. effusions after Fontan Hemodynamic targets

Getting the full picture Pre Op Assessment Anatomy – Review clinical data, ECG, CXR, Echo, Cath, CT/MRI, hematology etc Physiology – VSD TET TRANSPOSITION SINGLE VENTRICLE Intraop Assessment Anesthesia management, perfusion charts. Intraop TEE, Epicardial echo

Post Cardiac Surgical patient CPB related changes Changes related to cardiac surgery in general Changes specific to the Defect & the Surgery

ICU TROUBLESHOOTING BLOOD PRESSURE BREATHING BEATS BLEEDING BRAIN

When does Echo come in? Low Cardiac Output Preload LV Contractility (Afterload) Tamponade – IS A CLINICAL DIAGNOSIS Residual/ Additional/New Lesions Residual VSD, PFO, valve leaks, residual outflow tract obstruction, Baffle obstruction Pulmonary Hypertension – IVS position, RVSP RV function, Restrictive RV physiology

Echo in Post op Pediatric Cardiac Surgery Low PaO2 PFO / Fenestration - RT TO LT SHUNT Coronary sinus committed to LA BT shunts – Inadequate shunt/ Blocked shunt Overshunting leading to pul hem Tight PA Band Pulmonary Venous Obstruction after TAPVC repair, PAPVC repair Streaming issues (Contrast Echo)

Echo in Post op Pediatric Cardiac Surgery ALTERATION IN CLINICAL CONDITION Appearance or disappearance of murmurs Recurrence of MR after CAVC repair Chordal rupture after OMV Loosening of PA Band or Ligatures Occlusion of conduits, mech valves, coronaries. Paravalvar leaks Large Effusions - Pleural, Pericardial, Peritoneal Unusual Findings Pulse discrepancy after PDA ligation. Oligemic left lung field after PDA ligation.

Mild COA s/p PDA ligation

S/p PDA ligation

Main Limitation of Echo - views Getting the views with TTE interference due to air, dressings, drains Views are often better in children The view does improve with time If necessary, Trans esophageal echo is the choice, but size of the probe may be limiting in children.

3 D echo LA view of an OSASD

ASD What could possibly go wrong – No ASD? Pectus Pulmonary vein orifice/ CS mistaken for ASD Coronary sinus type ASD with partially or completely unroofed CS may be missed High PAPVC may be missed most mortalities in history of ASD surgery– Cor triatriatum.

False drop out

Absent RSVC, situs solitus, OSASD

Echo & Post op issues in ASD RA and RV may look baggy, CVP is usually low. Do not chase the CVP, if BP is alright. Desaturation – IVC to LA Baffle related problems – Pulmonary vein or systemic vein obstruction MR after Partial AV canal repair Recurrent pericardial effusions

Posterior ASD

VSD - 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 types

VSD - PHYSIOLOGY Shunts in Systole Shunt depends on size of the VSD and the SVR and PVR (Especially so if the VSD is nonrestrictive). Cath data often gives a clue Use Oxygen and IV fluids with caution Congestive Heart Failure in infancy, failure to thrive. Recurrent LRTI Eisenmenger Aortic regurgitation

VSD - Repaired Patch sewn across VSD

Echo in Post op issues Residual VSD Additional VSD Pulmonary hypertension TR AR RVOTO

AVSD - Anatomy

AVSD - Repaired

Echo after AV Canal repair Residual VSD/ASD/LV-RA shunt Left AV valve stenosis or regurgitation Right AV valve stenosis or regurgitation Pulmonary hypertension LVOTO Adequacy of ventricles

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

PDA - Repaired PDA Ligated via Left sided Thoracotomy

What could go wrong Residual PDA Ligated something else instead – Aortic isthmus (femoral art line) LPA (ETCO2 will fall) Residual COA Ductus tear Lung injury Recurrent laryngeal nerve injury Delayed – ductal aneurysm

Tetralogy of Fallot - Anatomy 3. Aortic Override 2. Subpulmonary Stenosis 1. VSD 4. Right Ventricular Hypertrophy

Tetralogy of Fallot - Repaired VSD Closed with Patch Infundibular Stenosis resected

Tetralogy of Fallot - Repaired

Echo after Tet repair Residual RVOTO Residual VSD RV dysfunction Restrictive RV physiology TR, PR Tamponade Desaturation (PFO Rt to Lt) Coronary crossing RVOT AR

TGA - Anatomy

TGA - 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 transfer

TGA – The ‘French’ Manoeuvre

To conclude Surgical input is a must in Post op ICU management of the cardiac surgical patient Echocardiography is our “Apat bandhava” and a very important member of the ICU team.

Thank You