1. Palliative Operation Seoul National University Hospital Department of Thoracic & Cardiovascular Surgery

2. Aims of Palliative Operations Purposes Operations have been designed to alter the hemodynamic physiology, to make the cardiac malformation more tolerable so as to allow improvement in the patient’s condition, to allow continued growth, and to by time. Three principal objectives Operations to increase pulmonary blood flow Operations to decrease pulmonary blood flow Operations to increase pulmonary-systemic mixing

3. Palliative Procedures in CHD 1 Systemic artery-pulmonary artery shunt Blalock-Taussing in 1945 Potts in 1946 Waterston in 1962 2 Systemic vein-pulmonary artery shunt Glenn in 1958 Fontan & Baudet in 1968 3 Pulmonary artery banding Muller & Dammann in 1952

4. Palliative Surgery Systemic – pulmonary artery shunt Blalock-Taussig shunt Unifocalization and shunt Cavopulmonary shunt (BCPS) RVOT reconstruction Valvotomy Patch widening Valved conduit Pulmonary artery banding Atrial septectomy

5. Systemic–Pulmonary Artery Shunt  Systemic – Pulmonary artery shunt is indicated due to age, size, anatomy or other conditions when; 1. Complex anomaly with severe cyanosis, irritability, hypoxic episode 2. Critically ill neonates or infants due to decreased pulmonary blood flow 3. Facilitating growth of hypoplastic pulmonary artery

6. Disadvantages of Classic B-T shunts 1. Longer operative dissection time 2. Phrenic nerve injury 3. Technical difficulties during takedown 4. Possible arm ischemia

7. Advantages of Sternotomy for Shunt 1) Less demanding for shunt construction with greater control of vessels without the risk of lung compression 2) Able to institute cardiopulmonary bypass 3) Complication rate is lower with even flow distribution 4) Single scar

8. RMBT Shunt (Midline Approach) BT Shunt

9. RMBT Shunt (Midline Approach) 1 m. TGA+VSD+PS BT Shunt

10. Bidirectional Cavo-pulmonary Connection BCPC

11. Bidirectional Cavo-pulmonary Connection BCPC

12. Bidirectional Cavo-pulmonary Connection 5m, SV+ PS BCPC

13. Thromboembolic Event after Shunt Incidence; 3~5% Etiology 1. Hematologic Inherited abnormality of coagulation factors Protein S, C, factor V Leiden, antithrombin III 2. Mechanical 3. Pulmonary hypertension 4. Infections Treatment Warfarin (reducing the Vk dependent proteins) Low-molecular weight heparin Newborns are low in Vk dependent protein( 50% of adult level, reach adult level at 6 months)

14. Control of congestive heart failure Complex or multiple VSD (with/without CoA) Single ventricle, Tricuspid atresia without PS Protection of pulmonary vascular bed Single ventricle – Fontan operation Preparation of LV for arterial switch operation TGA with IVS / restrictive VSD Pulmonary Artery Banding  Pulmonary artery banding is indicated to decrease pulmonary blood flow and prevent pulmonary vascular obstructive disease when ;

15. Pulmonary Artery Banding  Aims of banding To decrease the volume of the left to right shunt and thus the work of left ventricle, and minimize pulmonary vascular engorgement and protect the pulmonary vascular disease. ( Sick infants less than 6 months of age, or more, with intractable congestive failure and failure of growth, or with those complex lesions unsuitable for primary repair in infancy )

16. Pulmonary Artery Banding  Consequence 1 Mortality rate 2 Imperfect banding 3 Obliteration of pericardial space 4 Pulmonary artery distortion & maldistribution 5 Thickening of pulmonary valve 6 Subaortic stenosis

17. Pulmonary Artery Banding Diagnosis (ILI), Dextrocardia ECD, IVC interruption, 1 month old

18. Pulmonary Artery Banding F/3m, RV-type SV PA Banding

19. Pulmonary Artery Banding  Disadvantages 1. Failure to control adequate pulmonary blood flow 2. Distortion of pulmonary valve and artery 3. Progression of cardiac hypertrophy and subaortic obstruction 4. Changes of cardiac diastolic & systolic function

20. Mixing Procedures Operations to increase venous mixing of pulmonary-systemic venous returns 1.Rashkind septostomy by balloon catheter 2.Park blade atrial septostomy 3.Blalock-Hanlon closed atrial septectomy 4.Palliative atrial switch

21. Atrial Septectomy For the increase of effective pulmonary blood flow and systemic oxygen saturation Indications of atrial septectomy : TGA Tricuspid atresia Pulmonary atresia with intact vetricular septum MV & LV hypoplasia Decreasing tendency of indication due to early total correction or intervention