Presentation on theme: "Sri Sathya Sai Institute of Higher Medical Sciences"— Presentation transcript:
1 Sri Sathya Sai Institute of Higher Medical Sciences Surgical perspectives on Congenital Heart Disease Critical Care Update May 2010Dr. Pranav S KSri Sathya Sai Institute of Higher Medical SciencesBangalore
3 Two major issuesCardiac Surgeon and Post cardiac surgery Critical CareEchocardiography 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 gettingThere are things that surgeons can correctmany they cannotsome they may misssome they think they corrected but nature intended otherwiseAnd many things that surgeons can damage
6 BASIC SURGICAL PRINCIPLE Blue Blood to Pulmonary and Red blood to Systemic without any mixing and without any obstructionGlorified Plumbers ?
7 What inputs can a surgeon provide ? Curative vs PalliativeBiventricular vs Univentricular(vs one and a half ventricular repair)Single Stage vs Staged ProcedureOpen 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 findingsOperative details (in brief), with diagramOff clamp – Rhythm, PacingEvents coming off CPB, inotropes.What to look for from a surgical standpointe.g. effusions after FontanHemodynamic targets
15 Echo in Post op Pediatric Cardiac Surgery Low PaO2 PFO / Fenestration - RT TO LT SHUNTCoronary sinus committed to LABT shunts – Inadequate shunt/ Blocked shuntOvershunting leading to pul hemTight PA BandPulmonary Venous Obstruction after TAPVC repair, PAPVC repairStreaming 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.
19 Main Limitation of Echo - views Getting the views with TTEinterference due to air, dressings, drainsViews are often better in childrenThe view does improve with timeIf necessary, Trans esophageal echo is the choice, but size of the probe may be limiting in children.
22 ASD What could possibly go wrong – No ASD? Pectus Pulmonary vein orifice/ CS mistaken for ASDCoronary sinus type ASD with partially or completely unroofed CS may be missedHigh PAPVC may be missedmost mortalities in history of ASD surgery– Cor triatriatum.
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 LABaffle related problems – Pulmonary vein or systemic vein obstructionMR after Partial AV canal repairRecurrent pericardial effusions
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 clueUse Oxygen and IV fluids with cautionCongestive Heart Failure in infancy, failure to thrive.Recurrent LRTIEisenmengerAortic regurgitation