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Surgical perspectives on Congenital Heart Disease Critical Care Update May 2010 Dr. Pranav S K Sri Sathya Sai Institute of Higher Medical Sciences Bangalore.

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Presentation on theme: "Surgical perspectives on Congenital Heart Disease Critical Care Update May 2010 Dr. Pranav S K Sri Sathya Sai Institute of Higher Medical Sciences Bangalore."— Presentation transcript:

1 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 Cardiac Surgeon and Post cardiac surgery Critical Care Echocardiography and Surgeon and 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 There are things that surgeons can correct many they cannot many they cannot some they may miss some they may miss some they think they corrected but nature intended otherwise some they think they corrected but nature intended otherwise And many things that surgeons can damage 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 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 Curative vs Palliative Biventricular vs Univentricular Biventricular vs Univentricular (vs one and a half ventricular repair) Single Stage vs Staged Procedure Single Stage vs Staged Procedure Open or Closed (If Open then TCA +/-) Open or Closed (If Open then TCA +/-) Surgical Approach – Sternotomy, Thoracotomy, Minimally invasive. Open chest Surgical Approach – Sternotomy, Thoracotomy, Minimally invasive. Open chest

8 OTHER INPUTS Events prior to going on CPB Events prior to going on CPB Relevant intraoperative findings Relevant intraoperative findings Operative details (in brief), with diagram Operative details (in brief), with diagram Off clamp – Rhythm, Pacing Off clamp – Rhythm, Pacing Events coming off CPB, inotropes. Events coming off CPB, inotropes. What to look for from a surgical standpoint What to look for from a surgical standpoint e.g. effusions after Fontan e.g. effusions after Fontan Hemodynamic targets Hemodynamic targets

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10 Getting the full picture Pre Op Assessment Pre Op Assessment Anatomy – Review clinical data, ECG, CXR, Echo, Cath, CT/MRI, hematology etc Physiology – VSD TETTRANSPOSITION SINGLE VENTRICLE Intraop Assessment Intraop Assessment Anesthesia management, perfusion charts. Intraop TEE, Epicardial echo

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

12 BLOOD PRESSURE BLOOD PRESSURE BREATHING BREATHING BEATS BEATS BLEEDING BLEEDING BRAIN BRAIN ICU TROUBLESHOOTING

13 Preload Preload LV Contractility LV Contractility (Afterload) (Afterload) Tamponade – IS A CLINICAL DIAGNOSIS Tamponade – IS A CLINICAL DIAGNOSIS Residual/ Additional/New Lesions Residual/ Additional/New Lesions Residual VSD, PFO, valve leaks, residual outflow tract obstruction, Residual VSD, PFO, valve leaks, residual outflow tract obstruction, Baffle obstruction Baffle obstruction Pulmonary Hypertension – IVS position, RVSP Pulmonary Hypertension – IVS position, RVSP RV function, Restrictive RV physiology RV function, Restrictive RV physiology When does Echo come in? Low Cardiac Output

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15 PFO / Fenestration - RT TO LT SHUNT Coronary sinus committed to LA BT shunts –Inadequate shunt/ Blocked shunt BT shunts –Inadequate shunt/ Blocked shunt Overshunting leading to pul hem Tight PA Band Tight PA Band Pulmonary Venous Obstruction after TAPVC repair, PAPVC repair Streaming issues (Contrast Echo) Echo in Post op Pediatric Cardiac Surgery Low PaO2

16 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. Echo in Post op Pediatric Cardiac Surgery ALTERATION IN CLINICAL CONDITION

17 Mild COA s/p PDA ligation

18 S/p PDA ligation

19 Main Limitation of Echo - views Getting the views with TTE Getting the views with TTE interference due to air, dressings, drains Views are often better in children Views are often better in children The view does improve with time The view does improve with time If necessary, Trans esophageal echo is the choice, but size of the probe may be limiting in children. If necessary, Trans esophageal echo is the choice, but size of the probe may be limiting in children.

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21 3 D echo LA view of an OSASD

22 ASD What could possibly go wrong – What could possibly go wrong – No ASD? Pectus No ASD? Pectus Pulmonary vein orifice/ CS mistaken for ASD Pulmonary vein orifice/ CS mistaken for ASD Coronary sinus type ASD with partially or completely unroofed CS may be missed Coronary sinus type ASD with partially or completely unroofed CS may be missed High PAPVC may be missed High PAPVC may be missed most mortalities in history of ASD surgery– Cor triatriatum. 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. RA and RV may look baggy, CVP is usually low. Do not chase the CVP, if BP is alright. Desaturation – IVC to LA Desaturation – IVC to LA Baffle related problems – Pulmonary vein or systemic vein obstruction Baffle related problems – Pulmonary vein or systemic vein obstruction MR after Partial AV canal repair MR after Partial AV canal repair Recurrent pericardial effusions Recurrent pericardial effusions

26 Posterior ASD

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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

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31 VSD - PHYSIOLOGY Shunts in Systole 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 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 Use Oxygen and IV fluids with caution Congestive Heart Failure in infancy, failure to thrive. Congestive Heart Failure in infancy, failure to thrive. Recurrent LRTI Recurrent LRTI Eisenmenger Eisenmenger Aortic regurgitation Aortic regurgitation

32 VSD - Repaired Patch sewn across VSD

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

34 AVSD - Anatomy

35 AVSD - Repaired

36 Echo after AV Canal repair Residual VSD/ASD/LV-RA shunt Residual VSD/ASD/LV-RA shunt Left AV valve stenosis or regurgitation Left AV valve stenosis or regurgitation Right AV valve stenosis or regurgitation Right AV valve stenosis or regurgitation Pulmonary hypertension Pulmonary hypertension LVOTO LVOTO Adequacy of ventricles 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 Residual PDA Ligated something else instead – Ligated something else instead – Aortic isthmus (femoral art line) LPA (ETCO2 will fall) Residual COA Residual COA Ductus tear Ductus tear Lung injury Lung injury Recurrent laryngeal nerve injury Recurrent laryngeal nerve injury Delayed – ductal aneurysm Delayed – ductal aneurysm

40 Tetralogy of Fallot - Anatomy 1. VSD 2. Subpulmonary Stenosis 3. Aortic Override 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 RVOTO Residual VSD Residual VSD RV dysfunction RV dysfunction Restrictive RV physiology Restrictive RV physiology TR, PR TR, PR Tamponade Tamponade Desaturation (PFO Rt to Lt) Desaturation (PFO Rt to Lt) Coronary crossing RVOT Coronary crossing RVOT AR 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 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. Echocardiography is our Apat bandhava and a very important member of the ICU team.

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