1. CASE 3

2. Salient Features M.G. 2 y.o. girl “murmur” appreciated on PE Chest x-ray: – widened cardiac shadow with bulging of the left cardiac & supracardiac border with increased pulmonary vascularity 2D Echo: – VSD 8-9 mm, perimembranous subaortic type – PDA 3-4 mm with moderate pulmonary hypertension

3. Work ups before surgery Complete Pediatric, Medical, Maternal and Family History must be done Laboratory exams - CBC - Blood typing and Cross Matching - Creatinine Clearance - Skin Test - Bleeding Time, PT, aPTT

4. 3. Complications of surgery

5. Complications of Surgery Operative mortality –1 % –Increases with age, reoperation and multiple procedures Stroke –1-2 % incidence –Primary cerebrovascular disease in older pxs, atheroembolism from the ascending aorta, hypoperfusion, air embolism Sternal and mediastinal infection –1-2 % –Risk: diabetes, obesity, bilateral ITA grafting, prolonged preop hospitalization, multiple instrumentation –Use prophylaxis –Closure of the thymus and pericardium vs. mediastinitis Post surgery hemorrhage –2-5 % –From suture lines, branches of grafts and the ITA bed –Aspirin within 7 days can contribute

6. Safety of VSD Repair Reasonably safe < 2% risk of death –Exception: very sick patients with a large VSD and other defects Complications: – Haemorrhage – manage with blood transfusion – Infection – treat with antibiotics – Heart Block - deficit in conduction of the electrical signals between the upper and lower chambers

7. Complications of PDA Rare Short term:Hoarseness, paralyzed diaphragm, infection and bleeding Long-term: narrowing of the aorta, incomplete closure of the PDA, and reopening of the PDA

8. Surgical risk Surgical risk for PDA ligation is less than 1 %. Risk is higher: – in patients with chronic heart disease and chronic lung disease – Older patients with a fragile PDA

9. CONTRAINDICATIONS AND FOLLOW-UP Surgery should not be performed in patients with : – severe pulmonary hypertension – patients present with cyanosis. Follow-up after surgery: – Provide adequate medications and interventions for relief of temporary pain and feelings of discomfort – Restriction of activity Prognosis: – After complete recovery, the child should be able to eat better and gain proper weight. – He/She can also participate in normal activities. Regular follow up appointments with the cardiologist is necessary.