1. Cyanotic Heart Disease
THE “TERRIBLE T’s”
Cyanotic Heart Disease

2. GOALS
To define the physiology of the five most common cyanotic defects
To describe the long term sequelae of the corrective procedure.
To describe the PE,ECG, and CXR results for the more common defects.

3. INITIAL WORKUP: THE HYPEROXY TEST
Give the patient as close to FiO2 of 1 for at least 5 minutes.
Obtain pre and postductal ABG’S
What should your PaO2 be on 100% O2?
Is it reasonable to expect to get 100% using a mask or hood?

4. CXR
Mainly we are looking for situs, PBF, cardiac size and noncardiac abnormalities.
Boot shaped, apple shaped, box shaped, valentine shaped, egg on it’s side shaped, ball on string shaped, boiled peanut shaped…el toro poo poo.

5. ECG Get it! If you can’t read it fax it!
Remember most term infants have relative RV dominance so a big LV would be unusual.
Unless it’s a significant premie where there hasn’t been time to develop the pulmonary vascular bed. In a premie, RVE is not the norm

6. WHAT ARE THEY? Tetralogy of Fallot
d-Transposition of the great arteries
Truncus arteriosus
TAPVR
Atresia’s

7. TETRALOGY of FALLOT See handout for basics.
The primary concerns after correction are: the degree of Pulmonary insufficiency, the presence of tachydysrhymias, and residual VSD’s, and the presence of significant supravalvular pulmonary stenoses.
There seems to be a degree of mild learning disability post op, also ADHD.

8. d-TGA The most cyanotic common defect diagnosed in the nursery.
The degree of saturation will depend on the degree of mixing of the 2 “parallel” circuits.The mixing sites are: ASD, PDA, and VSD. The more mixing, the higher the “effective pulmonary blood flow”

9. EFFECTIVE PULMONARY FLOW
Blood going to the lungs which has not been to the lungs in that cardiac cycle.
PGE acts to increase mixing at the great vessel level.
BAS increases mixing at the atrial level
We try not to increase mixing at the ventricular level.

10. CLINICAL Findings d-TGA
Cyanosis
Possibly CHF
If pulmonary stenosis present, may be very blue
S2 normally split in 1/3, narrow and loud in 2/3
ECG: RAD with BE. May be wnl in nursery
CXR: egg on string.Narrow medias.^PBF

11. D-TGA cont. Cath findings: slides
ECHO: classic findings are anterior great vessel gives off CA’s, posterior vessel gives off two branches, may look like circle,circle

12. d-TGA TREATMENT
PGE: usually all that’s needed to improve mixing and relieve the acid base issues. At least long enough to get the patient to a center.
BAS may be necessary if PGE not effective and there’s a delay in correction.
MUSTARD: see slide
SWITCH

13. MUSTARD SEQUELAE
Sinus node dysfunction: 10 yrs out less than 30% in dominant sinus rhythm.
Atrial tachyarrhymias.
Ventricular arrhymias….sudden death
Coronary perfusion abnormalities
RV failure

14. ASO: follow -up
Supravalvular obstruction: most commonly PS with frequent LPA stenosis.
Coronary occlusion: occurs early. Had to correct if later
Neo-aortic regurg: more frequently reported. No cases requiring surgical correction but a few have required medical intervention

15. TAPVR
Cyanosis variable and largely dependant on degree of pulmonary venous obstruction.
CHF found in 41%, if early probably because of pulm vein obstruction. If later,in those without pn obs.
One of the few defects which can give you a big heart and cyanosis. The other is Ebsteins.

16. TAPVR cont. ECG: RAD,RVE, reversal of r/s progression,RAE by 3 months
Snowman on CXR
ECHO: usually a smallish LA, abnormalities of venous return(difficult to find any PV’s coming to LA). May find the common vein.

17. TAPVR
The patients are not infrequently our sickest as infants. The are profoundly hypoxic and frequently acidotic.
The biggest post-op issue is pulmonary vein stenosis. If that’s present, pulmonary HTN is inevitable and extremely difficult to tx.

18. TAPVR: ECMO
Because of the extreme condition many of these infant present in, some of them have been felt to have PPHN and have been submitted for ecmo. This was especially true before the availability of color doppler. This meant a number of these patients were in much better condition when they went for repair.

19. TRUNCUS ARTERIOSUS
A SINGLE GREAT VESSEL ARISES FROM THE HEART AND GIVES OFF THE CA’S,PA’S AND AORTA.
19TH MOST COMMON CONGENITAL HEART DEFECT
ONE OF THE LESIONS ASSOCIATED WITH RIGHT ARCH AND AORTIC OVERRIDE.

20. TRUNCUS cont
4 basic types based on the source of PBF. The fourth is pulmonary atresia with vsd otherwise known as pseudotruncus.
11% of cases have interrupted aortic arch
The is associated DiGeorge syndrome
There may be associated pulmonary stenosis

21. Truncus
If there is no pulmonary obstruction, the dominant picture is CHF with varying degrees of cyanosis
There may be significant insufficiency of the truncal valves which can have 2-5 cusps.
Bounding pulses(it’s like a big PDA), There may be a continous murmur if the PA’s are tight

22. TRUNCUS ECG: LVE,RVE OR BE. OCC LAE CXR: RIGHT ARCH 30%, ^PBF
ECHO: USUALLY DIAGNOSTIC

23. TRUNCUS:Tx Decongestive tx pending surgery
Surgery consists of VSD closure and a graft to the PA’s.
Early surgery essential.The average age of death untreated is 5 wks.
Sequelae:depends on degree of truncal valve insufficiency and pulm artery obstruction