Beruflich Dokumente
Kultur Dokumente
3b
IV.
V.
VI.
VII.
References
1. PowerPoint
2.
Recording
3.
Schwartzs Principles of Surgery
LEFT-TO-RIGHT
(ACYANOTIC)
Patent Ductus Arteriosus (PDA)
Atrial Septal Defect (ASD)
Ventricular Septal Defect (VSD)
Endocardial Cushion Defect (ECD)
Partial Anomalous Pulmonary
Venous Return (PAPVR)
RIGHT-TO-LEFT
(CYANOTIC)
Tetralogy of Fallot (TOF)
Transposition of the Great
Arteries (TGA)
Hypoplastic
Left
Heart
Syndrome (HLHS)
NEWER CLASSIFICATION
(BASED ON BEST TREATMENT OPTION)
REPAIR
ONLY
PALLIATION
ONLY
REPAIR OR
PALLIATION
Dr. VILLANUEVA
Nov. 10, 2014
PDA
Truncus arteriosus
ASD
TAPVR
Aortic stenosis
Cor triatriatum
Aortic coarctation
Tricuspid atresia
Hypoplastic Left Heart Syndrome (HLHS)
VSD
TOF
TGA
Taussig-Bing Syndrome (TBS) w/ or w/o pulmonary
stenosis (PS)
Atrioventricular canal defects
Interrupted aortic arch
Ebsteins Anomaly
DORV (Double Outlet Right Ventricle)
DORV with NON-committed VSD
DORV with Subaortic/doubly committed VSD w/o PS
DORV with Subaortic or doubly committed
A right PDA joins the right pulmonary artery and the right aortic arch
just distal to the right subclavian artery
Edited by: MJ NG
Page 1 of 12
SURGERY II 4.3B
EPIDEMIOLOGY OF PDA IN FULL TERM INFANTS
May be genetic
1.
2.
3.
SMALL PDA
MODERATE
PDA
LARGE PDA
CLINICAL MANIFESTATIONS
Few patients are symptomatic
Attention is often brought to this condition only by the
murmur
Detected at a routine physical examination
Symptomatology related to left ventricular failure
o Poor feeding, irritability, and tachypnea
o Poor weight gain
The symptoms increase until about the second to third
month of age
Symptoms indicative of severe left ventricular failure
with pulmonary edema may occur early in infancy
o Irritable, feed poorly, fail to gain weight, sweat
excessively
o Increased respiratory effort and respiratory rates
o Recurrent upper respiratory infections and
pneumonia
PHYSICAL EXAMINATION
**SEE APPENDIX A
Murmur
o Grade 1-4/6 continuous (machinery) murmur is best audible
at the left infraclavicular area or upper left sternal border
o The heart murmur may be crescendo systolic at the upper left
sternal border in small infants or infants with pulmonary
hypertension
o An apical diastolic rumble may be heard when the PDA shunt is
large
Hyperactive precordium
LABORATORY RESULTS
Chest radiograph
o Increased pulmonary vascularity
o Cardiomegaly
ECG
o LV strain, LA enlargement, possible RV hypertrophy
Echocardiogram
o Demonstration of duct patency and shunt size
Edited by: MJ NG
Page 2 of 12
SURGERY II 4.3B
NATURAL COURSE
Spontaneous closure in premature infants.
In term infants spontaneous closure rarely occurs
CHF and/or recurrent pneumonia develop in large PDA
PVOD
Sub-acute bacterial endocarditic
Aneurysm rare
MANAGEMENT
MEDICAL
For preterm infants: Indomethacin or Ibuprofen (Contraindications:
renal insufficiency, necrotizing enterocolitis)
For term infants: those unresponsive to Indomethacin must undergo
mechanical closure
No exercise restriction is needed in the absence of pulmonary
hypertension
Prophylaxis for subacute bacterial endocarditis is indicated when
indications arise
Treatment of symptomatic patients with CHF
o Diuretics to decrease blood volume going to pulmo circulation
o Digoxin to increase heart contractility
o After-loader reducing agents to prevent blood shunt from
aorta; lower systemic resistance so blood goes preferentially to
systemic circulation)
CATHETER CLOSURE (STUDY)
COIL CLOSURE PROCEDURE
Treatment of choice for all children more than a few months of age
with ducts <3 mm in diameter
Performed using conscious sedation allowing the children to return to
full activity by the next day
A catheter is advanced from femoral artery or vein across the PDA
An occluding coil is placed in the PDA with a single coil loop on the
pulmonary artery side and the remaining three to four loops in the
ductal ampulla
>97% successful with zero mortality and no significant morbidity
Percutaneous technique
AMPLATZER DUCT OCCLUDER
For larger PDAs 12 mm in diameter
Procedure is similar in duration, risk, and recovery time to the coil
closure procedure
The devices are implanted antegrade from the femoral vein using
long sheaths sized 6 to 8 French.
> 98% closure rate at 6 months with minimal complications and no
mortality
Edited by: MJ NG
Page 3 of 12
SURGERY II 4.3B
ATRIAL SEPTAL DEFECT
OSTIUM SECUNDUM
Most prevalent (80% of ASD)
Only type that may spontaneously close
Results from failure of closure in neonate
OSTIUM PRIMUM
Near the area of the valve
May lead to mitral regurgitation Heart failure
SINUS VENOSUS
Nearest to the roof of the heart
Partial anomalous pulmonary venous return
Ostium Primum and Sinus Venosus are both failure in the growth of
septum
LAB FINDINGS
Chest Radiograph: right atrial enlargement, right ventricular
enlargement, prominent pulmonary artery, increased pulmonary
vascular markings
ECG: right axis deviation, mild right ventricular hypertrophy, right
bundle-branch block
2D Echo
o 'Dropout' mid atrial septum indicative of an ostium secundum
type of ASD
o Drop out is lower ostium primum
o Drop out is higher sinus venosus
[2]
**Drop-out is the defect
Scimitar sign: true anomalous venous return of the right pulmonary
veins into the inferior vena cava (rather than directly to the left
atrium)
MANAGEMENT
NONSURGICAL OR PERCUTANEOUS CLOSURE
Usually used for ostium secundum
Use of septal occlude or pericardium
SURGICAL CLOSURE
Surgery indication:
o Qp/Qs > 1.5:1
Qp pulmonary flow; Qs systemic flow
Contraindication: pulmonary vascular resistance ( 10 U/m2 )
Timing of surgery is delayed until 3-4 years old because of possible
spontaneous closure
Complications: CVA, arrhythmia
o Heart block: ostium primum AV node
o Sinus node dysfunction: sinus venosus posterosuperior of SVC
PRIMARY CLOSURE
Usually done in pediatric patients
PATCH CLOSURE
Using pericardium or Teflon
Usually done in adult patients; pericardium is usually used except for
high pressure like LV, synthetic grafts are used instead[2]
DIAGNOSIS
Associated with right ventricular hypertrophy from the very start; in
contrast to most L-R shunts where LVH is present
Usually asymptomatic (patients with complaints are usually in their
2ndto 3rd decade of life already)
The amount of blood shunted across the defect is low because the
atria are both low-pressure chambers.
Edited by: MJ NG
Page 4 of 12
SURGERY II 4.3B
VENTRICULAR SEPTAL DEFECT
OUTFLOW
Outlet, supracristal, infundibular, doubly committed subarterial
5 to 7%
A defect within the conal septum
Beneath the pulmonary valve
No chance of spontaneous closure
INLET
Atrioventricular canal defects
5 to 8%
Part or all of the septum of the AV canal is absent
Posterior and inferior to perimembranous defect, beneath the septal
leaflet of tricuspid valve and inferior to the papillary muscles
MUSCULAR
5 to 20%
Can occur anywhere along the trabecular septum
o Central: mid-muscular, may have multiple apparent channels on
right ventricle side; coalesce to a single defect on left ventricle
side
o Apical: multiple apparent channels on RV, maybe single defect in
LV side as with central defect
o Marginal: along septal margin
o Swiss cheese septum: large number of muscular defects
[1]
A.
B.
[1]
SMALL
MEDIUM
LARGE
Poor weight
gain Signs of
CHF
Normal precordial
activity (+/-) thrill in the
lower left sternal border
associated with Grade 46 holosystolic murmur
Heart sound: usually
normal
Hyperdynamic precordium
Extended L & R ventricular
areas (+) thrill, holosystolic
murmur S2 widely split P2
normal or slightly increased
Left anterior
precordial
bulge after
4-6 months
Edited by: MJ NG
Page 5 of 12
SURGERY II 4.3B
SMALL
DIAGNOSIS[1]
MEDIUM
ECG: Normal
LVH/LAH
CXR: Normal
LARGE
Combined ventricular
hypertrophy
Biventricular enlargement
Increased pulmonary vascular
marking
NATURAL HISTORY
Spontaneous Closure most small VSDs, 20-30% close before 1 year
old
Congestive heart failure large VSDs
o Extra blood flows from the LV thru the RV to the lungs LA
LV causes LA and LV overload increase workload on the
heart increased HR and bodys demand for energy
o Extra blood flow in the lungs rapid breathing, also increasing
the bodys demand for energy
Growth failure seen in infants
o Baby is not able to eat enough to keep up with the bodys
increased energy demands
Bacterial endocarditis
Arrhythmia
Pulmonary HPN sustained flow under higher pressure into the
pulmonary arteries causes the arteries to become thickened and stiff.
The amount of blood flow to the lungs decreases over time as the
resistance to blood flow into the pulmonary arteries increases.
However, this causes the right ventricle to work harder.
TETRALOGY OF FALLOT
MANAGEMENT
NONSURGICAL
Small: None except antibiotic prophylaxis
Moderate to large:
o Furosemide (1-3 mg/k/day)
o High caloric diet
o Captopril (0.1 -0.3 mg/kg TID)
o Digoxin if diuresis and afterload reduction not enough and
surgery not advisable
SURGICAL APPROACH
Indications
Page 6 of 12
SURGERY II 4.3B
MANIFESTATION
Cyanosis (significant when 6-12mos of life), tachypnea, clubbing
Grade 3-5/6 systolic ejection murmur
Polycythemia develops secondary to cyanosis
Hypoxic spells in infants (tet spells), periods of extreme hypoxemia
Subacute bacterial endocarditis a common complication
DIAGNOSIS
ECG: right axis deviation, right ventricular hypertrophy, combined
ventricular hypertrophy, right atrial hypertrophy
CXR: boot-shaped heart (couer en sabot)
Fig11. TOF with Modified Blalock-Taussig Shunt
Pag maliit ang pulmonary artery (due to stenosis), you cannot do an
outright connection. So, we increase the blood flow to pulmonary arteries.
We create a shunt shunt systemic blood to PA, para dumami yung blood
na dadaan sa lungs. Thus, more oxygenated blood to go to LA and LV.
[3]
TRANSATRIAL REPAIR
Use of transannular patch
It involves the use of cardiopulmonary bypass
TRANSPOSITION OF GREAT ARTERIES
Propranolol
Treat Fe deficiency anemia
Dental hygiene & subacute bacterial endocarditis prophylaxis
Balloon dilatation of RVOT & pulmonary valve
SURGICAL APPROACH
Optimal age of approach is not yet determined. Currently primary
elective repair is preferred for infancy[3]
Surgical correction of TOF can either be:
o a staged approach of antecedent palliation in infancy followed
by intracardiac repair
o primary repair during first few months of life without palliative
surgery.
Primary goal: increase the flow of blood going to the pulmonary
circulation. For total correction of TOF, the stenotic outflow tract is
opened and the septal defect is repaired (i.e. patch closure). This is
not possible at all times, which is why palliation may be initially
required.
DISADVANTAGE: it has the resultant scar that would significantly
[3]
impair right ventricula function that may lead to lethal arrhythmias
MODIFIED BLALOCK-TAUSSIG SHUNT (BTS)
Antecedent palliation with the use of systemic-to-pulmonary shunts
is preferred in unstable infants younger than 6 months of age
o Those who have pulmonary atresia, significant branch
pulmonary artery hypoplasia or require an extracardiac conduit
because of an anomalous left anterior descending coronary
artery
3% mortality rate
Complications: right bundle-branch block, complete heart block,
congestive heart failure, pulmonary regurgitatation
Edited by: MJ NG
Page 7 of 12
SURGERY II 4.3B
Figure 15.CorTriatriatum.
(A) Common chamber draining to right atrium directly. (B) Common
chamber draining into systemic venous circulation via an anomalous vein.
MANAGEMENT
ARTERIAL SWITCH OPERATION by JATENE
THERAPY
Cardiopulmonary bypass & cardioplegic arrest are used.
Just remove the membrane
SENNING OPERATION
Edited by: MJ NG
Page 8 of 12
SURGERY II 4.3B
o
o
AORTIC COARCTATION
ANATOMY
Defined as a luminal narrowing in the aorta that causes an
obstruction to blood flow, usually located distal to the left subclavian
artery.
Causes extensive collateral circulation
Page 9 of 12
SURGERY II 4.3B
Figure 19. Collete Edwards (Type I-III) and Van Praagh (A1-A4)
Page 10 of 12
Surgery II 4.3b
Dr. VILLANUEVA
Nov. 10, 2014
APPENDIX A. PHYSICAL EXAMINATION FINDINGS OF PDA DEPENDING ON ITS DIAMETER AND LENGTH
PHYSICAL EXAMINATION
PERIPHERAL
PULSE
ARTERIAL
PULSE
PRESSURE
PRECORDIAL
ACTIVITY
HEART SOUND
SMALL PDA
May be full
Slightly
increased
MODERATE
PDA
Increased
HR
Bounding
Wide
(Low
diastolic
Pressure)
Hyperdynamic
Thrusting
apical pulse
S1 and S2
difficult
to
hear due to
loud murmur
S3 apex
LARGE PDA
Increased
HR
Bounding
Wide
Markedly
hyperdynamic
Thrusting left
ventricular
apical impulse
S1 and S2
accentuated
S3 Apex
Normal
S1 and S2
Normal
MURMUR
OTHERS
In early infancy
May be a short period when no murmur is
heard
Short systolic murmur may then be heard
In late infancy to older children
Typical, continuous murmur heard best in the
second lics
Often accentuated at recumbent position or
during inspiration
Continuous murmur:
o More intense, more extensive radiation, and
well heard posteriorly
o Much harsher quality with low-frequency
components
o Eddy sounds that vary from beat to beat
give the murmur a machinery quality
No murmur is heard with severe failure
With control of left ventricular failure:
moderately loud systolic murmur in the
pulmonary area or occasionally in 3rd or 4th ics
The typical continuous murmur is less usual
Prominent mid-diastolic mitral flow rumble is
commonly audible at the apex
If w/ pulmonary
edema, rales on
all lung fields
MEDIUM
PDA
Normal
Slight prominence of MPA
Cardiomegally
o LVH and LAE
prominent MPA
increased PVM
prominent ascending
unfolding of arch
LARGE PDA
ECG
2D Echo
Normal
with
aorta
Edited by: MJ NG
Page 11 of 12
Surgery II 4.3b
Dr. VILLANUEVA
Nov. 10, 2014
Edited by: MJ NG
Page 12 of 12