1. 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

2. Humble Pranams at the Lotus Feet of Bhagwan

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

4. 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

5. The blood brain barrier

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

7. 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”

8. 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

10. 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

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

12. ICU TROUBLESHOOTING
BLOOD PRESSURE
BREATHING
BEATS
BLEEDING
BRAIN

13. 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

15. 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)

16. 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.

17. Mild COA s/p PDA ligation

18. S/p PDA ligation

19. 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.

21. 3 D echo LA view of an OSASD

22. 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.

23. False drop out

24. Absent RSVC, situs solitus, OSASD

25. 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

26. Posterior ASD

28. 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

29. VSD types

31. 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

32. VSD - Repaired
Patch sewn across VSD

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

34. AVSD - Anatomy

35. AVSD - Repaired

36. 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

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

38. PDA - Repaired
PDA Ligated via Left sided Thoracotomy

39. 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

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

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

42. Tetralogy of Fallot - Repaired

43. 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

44. TGA - Anatomy

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

46. Arterial Switch & coronary transfer

47. TGA – The ‘French’ Manoeuvre

48. 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.

49. Thank You