Surgical perspectives on Congenital Heart Disease Critical Care Update May 2010

1. Surgical perspectives on Congenital Heart DiseaseCritical Care Update May 2010 Dr. Pranav S K Sri SathyaSai 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 • 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 • many they cannot • some they may miss • some they think they corrected but nature intended otherwise • 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 Glorified Plumbers ?

7. What inputs can a surgeon provide ? • Curative vs Palliative • Biventricular vsUniventricular (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”

8. 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

10. 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

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

12. ICUTROUBLESHOOTING • BLOOD PRESSURE • BREATHING • BEATS • BLEEDING • BRAIN

13. 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

15. Echo in Post op Pediatric Cardiac SurgeryLow 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)

16. Echo in Post op Pediatric Cardiac SurgeryALTERATION 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.

17. Mild COA s/p PDA ligation

18. S/p PDA ligation

19. 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.

21. 3 D echo LA view of an OSASD

22. 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– Cortriatriatum.

23. False drop out

24. Absent RSVC, situssolitus, 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. • Desaturation – IVC to LA • Baffle related problems – Pulmonary vein or systemic vein obstruction • MR after Partial AV canal repair • Recurrent pericardial effusions

26. Posterior ASD

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

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 clue • Use Oxygen and IV fluids with caution • Congestive Heart Failure in infancy, failure to thrive. • Recurrent LRTI • Eisenmenger • Aortic regurgitation

32. VSD - Repaired Patch sewn across VSD

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

34. AVSD - Anatomy

35. AVSD - Repaired

36. 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

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 • 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

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

49. Thank You