Surgical perspectives on
Congenital Heart Disease
Critical Care Update
May 2010
Dr. Pranav S K
Sri Sathya Sai Institute of Higher
Medical Sciences
Bangalore
Humble Pranams at the Lotus Feet of
Bhagwan
Two major issues
Cardiac Surgeon and Post cardiac surgery
Critical Care
 Echocardiography and Surgeon and critical
care

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
 many they cannot
 some they may miss
 some they think they corrected but nature
intended otherwise


And many things that surgeons can
damage
The blood brain barrier
BASIC SURGICAL
PRINCIPLE
Blue Blood to Pulmonary
and Red blood to Systemic
without any mixing and
without any obstruction
Glorified Plumbers ?
What inputs can a surgeon provide ?
Curative vs Palliative
 Biventricular vs Univentricular
(vs one and a half ventricular repair)
 Single Stage vs Staged Procedure
 Open or Closed (If Open then TCA +/-)
 Surgical Approach – Sternotomy,
Thoracotomy, Minimally invasive. “Open
chest”

OTHER INPUTS
Events prior to going on CPB
 Relevant intraoperative findings
 Operative details (in brief), with diagram
 Off clamp – Rhythm, Pacing
 Events coming off CPB, inotropes.
 What to look for from a surgical standpoint
e.g. effusions after Fontan
 Hemodynamic targets

Getting the full picture

Pre Op Assessment
Anatomy – Review clinical data, ECG, CXR,
Echo, Cath, CT/MRI, hematology etc
Physiology –
VSD
TET
TRANSPOSITION
SINGLE VENTRICLE

Intraop Assessment
Anesthesia management, perfusion charts.
Intraop TEE, Epicardial echo
Post Cardiac Surgical patient
CPB related changes
 Changes related to cardiac surgery in general
 Changes specific to the Defect & the Surgery

ICU TROUBLESHOOTING
 BLOOD
PRESSURE
 BREATHING
 BEATS
 BLEEDING
 BRAIN
When does Echo come in?
Low Cardiac Output
Preload
 LV Contractility
 (Afterload)
 Tamponade – IS A CLINICAL DIAGNOSIS
 Residual/ Additional/New Lesions
Residual VSD, PFO, valve leaks,
residual outflow tract obstruction,
Baffle obstruction
 Pulmonary Hypertension – IVS position, RVSP
 RV function, Restrictive RV physiology

Echo in Post op Pediatric Cardiac Surgery
Low PaO2
PFO / Fenestration - RT TO LT SHUNT
Coronary sinus committed to LA
BT shunts – Inadequate shunt/ Blocked shunt
Overshunting leading to pul hem
Tight PA Band
Pulmonary Venous Obstruction after TAPVC
repair, PAPVC repair
Streaming issues (Contrast Echo)
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.
Mild COA s/p PDA ligation
S/p PDA ligation
Main Limitation of Echo - views
Getting the views with TTE
interference due to air, dressings, drains
 Views are often better in children
 The view does improve with time
 If necessary, Trans esophageal echo is the
choice, but size of the probe may be
limiting in children.

3 D echo LA view of an OSASD
ASD

What could possibly go wrong –
No ASD? Pectus
Pulmonary vein orifice/ CS mistaken for ASD
Coronary sinus type ASD with partially or
completely unroofed CS may be missed
High PAPVC may be missed
most mortalities in history of ASD surgery–
Cor triatriatum.
False drop out
false neg a4c.avi
Absent RSVC, situs solitus, OSASD
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 LA
 Baffle related problems – Pulmonary vein or
systemic vein obstruction
 MR after Partial AV canal repair
 Recurrent pericardial effusions

Posterior ASD
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
VSD types
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 clue
 Use Oxygen and IV fluids with caution

Congestive Heart Failure in infancy, failure
to thrive.
 Recurrent LRTI
 Eisenmenger
 Aortic regurgitation

VSD - Repaired
Patch sewn
across VSD
Echo in Post op issues
Residual VSD
 Additional VSD
 Pulmonary hypertension
 TR
 AR
 RVOTO

AVSD - Anatomy
AVSD - Repaired
Echo after AV Canal repair
Residual VSD/ASD/LV-RA shunt
 Left AV valve stenosis or regurgitation
 Right AV valve stenosis or regurgitation
 Pulmonary hypertension
 LVOTO
 Adequacy of ventricles

PDA - Physiology
Blood flows
from the Aorta
across the duct
into the
Pulmonary
Arteries
resulting in
increased
Pulmonary
Blood Flow
PDA - Repaired
PDA Ligated via
Left sided
Thoracotomy
What could go wrong
Residual PDA
 Ligated something else instead –
Aortic isthmus (femoral art line)
LPA (ETCO2 will fall)
 Residual COA
 Ductus tear
 Lung injury
 Recurrent laryngeal nerve injury
 Delayed – ductal aneurysm

Tetralogy of Fallot - Anatomy
3. Aortic Override
2.
Subpulmonary
Stenosis
4. Right
Ventricular
Hypertrophy
1. VSD
Tetralogy of Fallot - Repaired
VSD Closed with
Patch
Infundibular
Stenosis resected
Tetralogy of Fallot - Repaired
Echo after Tet repair
Residual RVOTO
 Residual VSD
 RV dysfunction
 Restrictive RV physiology
 TR, PR
 Tamponade
 Desaturation (PFO Rt to Lt)
 Coronary crossing RVOT
 AR

TGA - Anatomy
TGA - Physiology
Two Circuits in
parallel, the
only mixing
occurs at the
level of the
duct, patent
foramen ovale
or VSD if
present
Arterial Switch & coronary transfer
TGA – The ‘French’ Manoeuvre
To conclude

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.