The complications of cardiac surgery: a walk on the Dark Side? Prof Rik De Decker Red Cross Children’s Hospital
CME Nov/Dec 2011 http://www.cmej.org.za
Why should you care? You are about to leave your office after a hectic Friday, and are looking forward to a quiet weekend off. Just as you reach the door, the phone rings, and your first instinct is to ignore it. But you answer it anyway. It is a Mrs Harmse, in a panic. Then you recall: you had sent her 8-month-old son, Karl, who has tricuspid atresia, to Red Cross Hospital 6 weeks ago. Karl had become very blue when his Blalock-Taussig shunt, inserted 7 months ago, blocked. This time, she says, he has had diarrhoea for 3 days, he has become very blue again, and his face is now horribly swollen! She reads from his discharge letter from RXH, which says something about a “successful heart operation 4 weeks ago with a Glenn…”
Do you wonder … .? Who is this Glenn bloke, and why did he make Karl’s head swell up? Or do you suspect … .? Karl’s been dehydrated by his diarrhoea, … so his Glenn shunt has thrombosed, … causing poor flow to his branch PAs and SVC syndrome! I’d better get him to RXH now!
What does cardiac surgery do? Cardiac surgery (and cath interventions) removes or palliates physiological processes that lead to morbidity or death … but it replaces them with other, more benign ones, that may not be entirely innocent.
What are those (less innocent) processes ? The incorrect perception by parents that The Operation has been done, and all is well...
The life-line of a child with tricuspid atresia ADMISSIONS CARDIAC CLINIC Clinical assessment ECG SIGNIFICANT EVENTS ROUTINE VISITS ECG Echo Echocardiography Clinical assessment Cardiac catheterisation CT angiogram Non-cardiac investigations REFERRAL TO ADULT SERVICE Pre-op medical management Surgery Post-op TOE Post-op ICU echocardiograms Post-op catheterisation Twice daily ICU rounds Antenatal/Birth Teenage years Twice daily ward rounds Discharge work-up Echo ECG Bloods
The unnatural history of post-op CHD • recoarctation • hypertension • PA distortion • shunt obstruction • LA enlargement • LV hypertrophy • PA aneurysm • RV failure • arrhythmias • liver failure • … . etc, etc
Some common misconceptions • Heart surgery is corrective • Late post-op complications are rare • Parents usually know what is wrong with their child’s heart • Only cardiologists need to know about heart operations • Paediatric cardiologists hate being disturbed
Large variety of operations - from “simple” to complex
Five operative categories - by their longer-term outlook 1. temporary palliation for defects that cannot be repaired initially PA BAND SHUNTS 2. operations for heart defects that are “fully corrected” at the first procedure COARCTATION TAPVD TGA 1. heart defects that might require further surgery or intervention after repair TETRALOGY COARCTATION 2. heart defects that will definitely require further surgery after the initial procedure HOMOGRAFT FOR PA/VSD 1. long-term palliation of uncorrectable lesions: functionally univentricular hearts GLENN & FONTAN SHUNTS
Temporary palliation for defects that cannot initially be repaired • Blalock-Taussig shunts (BTS) • Central shunts • Pulmonary artery bands (PABs) Palliative operations provide symptomatic relief but leave the basic pathophysiology uncorrected. • t hey may create the false impression that “the operation” has been done. • the patient is often lost to follow-up, and the late post-op mortality is consequently very high.
BT shunts (and a central shunt) Left BT shunt Right BT shunt Central shunt Temporary palliation for defects that cannot initially be repaired
PA band Aorta Aorta LPA MPA MPA Temporary palliation for defects that cannot initially be repaired
Operations for heart defects that are “fully corrected” at the first procedure • Patent ductus arteriosus (PDA) • Coarctation of the aorta • Atrial septal defect (ASD) • Ventricular septal defect (VSD) • Atrioventricular septal defect (AVSD) • Total anomalous pulmonary venous drainage (TAPVD) • Transposition of the great arteries (TGA) • Anomalous left coronary artery from the pulmonary artery (ALCAPA)
End-to-end coarctation repair Operations for heart defects that are “fully corrected” at the first procedure
Aortic switch operation for TGA Operations for heart defects that are “fully corrected” at the first procedure
Aortic switch operation for TGA Operations for heart defects that are “fully corrected” at the first procedure
Heart defects that might require further surgery or intervention after repair • Tetralogy of Fallot (TOF) PV replacement for Fallot – by far the most common redo procedure in adult congenital heart surgery • Transposition of the great arteries (TGA) • Ebstein’s anomaly Mr Tim Jones Adult CHD surgery
Heart defects that will require further surgery after the initial procedure • Homografts – Pulmonary atresia with VSD (PA/VSD) – Truncus arteriosus • Transposition with pulmonary stenosis (TGA/PS) • Congenital aortic stenosis (AS) • Left ventricular outflow tract obstructions (LVOTO) • Permanent pacemaker (PPM)
Homograft repair (Rastelli) Heart defects that will require further surgery after the initial procedure
Homografts always spell trouble! • They do not grow with the patient • Complications include – PS and PR – aneurysm formation – branch pulmonary stenoses – calcification – endocarditis – RV failure • They need surgical replacement every 5- 10 years!
Long-term palliation of uncorrectable lesions: the Fontan circulation (TCPC) for functionally univentricular hearts • Tricuspid atresia • Double inlet left or right ventricle (DILV/DIRV) • Univentricular heart (UVH) • Hypoplastic left heart syndrome (HLHS)
The Glenn shunt Heart defects that will require further surgery after the initial procedure
The Fontan operation
The 10 “commandments” for a Fontan repair Choussat A, Fontan F, Besse P (1977) Selection criteria for the Fontan procedure. In: Anderson RH, Shinebourne EA (eds) Paediatric 1. Age > 4 years 33 years later … cardiology. Churchill Livingstone, Edinburgh, Scotland, pp 559 – 566 2. Sinus rhythm 3. Normal systemic venous return “It is clear from a historic perspective that total 4. Normal right atrial volume compliance with all criteria does not necessarily 5. Mean pulmonary artery pressure <15 mm Hg portend excellent long-term survival … . I suggest 6. Pulmonary arteriolar resistance <4 Wood units/m 2 the following single commandment: 7. Pulmonary artery – aorta ratio >0.75 ‘‘ Thou Shalt Be Perfect! ” 8. Left-ventricular ejection fraction >0.60 9. Competent mitral valve Fontan ‘‘Ten Commandments’’ Revisited and 10. Absence of pulmonary artery distortion Revised Stern H . Pediatr Cardiol (2010) 31:1131 – 1134
Post-op complications of heart surgery • Early: usually not your problem • Late – wound sepsis – pericardial effusion – pleural effusion – obstruction – endocarditis – arrhythmias – cardiac failure – liver failure – protein losing enteropathy – etc, etc …
Specific complications • Shunts blockage, seroma • PA bands slippage, PR, branch PA stenosis • Glenn stenosis, blockage, SVC syndrome • Fontan pleural effusions, liver failure • Tetralogy RV failure, arrhythmias • PA/VSD PA stenosis, PR, RV failure
What scar is that? • median sternotomy – all bypass cases, Glenn, Fontan • right lateral thoracotomy – RMBTS • left lateral thoracotomy – LMBTS, coarctation, PAB • mini sternotomy – pericardial effusion • left subcostal – permanent pacemaker • right minithoracotomy – ASD repair
Cardiac cath interventions 1. PDA occlusion 2. PDA stenting 3. ASD occlusion 4. VSD occlusion 5. Atrial septostomy 6. Relief of PA stenosis 7. Relief of conduit stenosis 8. Coarctation of aorta stenting 9. Aortic valvuloplasty 10. Pulmonary valvuloplasty 11. RV outflow tract stenting 12. Opening obstructed shunts 13. Recruiting disconnected PAs 14. Creating or closing Fontan fenestrations 15. Occlusion of pulmonary AVMs 16. Occlusion of PAPVD 17. Occlusion of coronary cameral fistulae 18. Occlusion of carotid-jugular fistula 19. Stenting of Takayasu aortitis 20. Myocardial biopsy 21. Renal artery stenoses 22. Retrieval of foreign bodies 23. Pericardiocentesis
In conclusion What is a GP to do? • Panic • Treat the symptoms and signs as best you can • Phone a friend – talk to them frequently • Maintain “ownership” of your patient – shared care! • Learn to echo! UCT PG DIPLOMA IN PAEDIATRIC CARDIOLOGY
Shared care? CARDIAC CLINIC Clinical assessment Medication (INR, ECG, Echo) SIGNIFICANT EVENTS ROUTINE VISITS REFERRAL TO ADULT SERVICE Antenatal/Birth Teenage years rik.dedecker@uct.ac.za
Thank you for your attention!
The cardiac surgeon’s idea of a waiting list.. A very cute patient
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