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CommonCardiac Surgeries
inChildren
Dianna M. E. Bardo, M. D. Director of Cardiac Radiology
Associate Professor of Radiology,Pediatrics, & Cardiovascular Medicine
Disclosure
Consultant & Speakers Bureau – honorariaKoninklijke Philips Healthcare
definitions & a reality checkMalformationA primary structural defect arising from a localized error in morphogenesis
- results in the abnormal formation of an organ
DysplasiaRefers to an abnormal organization of cells into tissues
repaircomplete anatomic correction of congenital heart defect
palliationprovides physiologic correction of blood flow
g- results in abnormal tissues
The distinction of malformation from dysplasia is at best blurry – there is much overlap
the right and left sides are normally separate circulationsseparated by the pulmonary capillary bed
intracardiac & t di h t
normal cardiac circulation
extracardiac shuntsin utero – 2 normal shunts
foramen ovaleductus arteriosus
postnatal abnormal shuntsASD VSD PDAtruncus arteriosus
patent ductus arteriosusdivision & over-sewing
1938Gross – Children’s Hospital Boston
triple ligation technique1946
Performed when he was Chief Resident & his surgical chairman was out of town!
Blalock – Johns Hopkinspharmacologic closure
indomethacin
1976Heymann
Catheter basedcoil or device closure
1993
patent ductus arteriosuspost-surgical findings, complications & re-op indications
essentially noneneed for re-imaging
virtually none
patent foramen ovalecloses as right heart pressures increase postnatally
primum – AVSD
atrial septal defectclosed technique
late 1940s & early 1950sBailey & Sondergaard (separately)
open repair technique1952Gross – Children’s Hospital Boston
secundum
sinus venosus
Gross Children s Hospital Bostondirect visualization
1953 – Lewis & Tauficusing cardiopulmonary bypass
1954 – Gibbons
Catheter based device closure
1997 – Matsura
atrial septal defectpost-surgical findings, complications & re-op indications
essentially none
need for re-imagingvirtually noneresidual ASD
membranous paramembranous muscular
ventricular septal defectPA banding – palliation of VSD
1952 – Muller & DammannVSD closure
1954 – Lillehei – U of Minnesotausing a heart-lung machine
1955 – Kirklin – Mayo Clinic single multiple
spontaneous closure
surgical & instrumented closure
1955 Kirklin Mayo Clinictransatrial closure
1958 –Stirlingtotal circulatory arrest
1969 – Okamoto deep hypothermia & arrest
Barratt-BoyesAmplatz closure device
1999 - Thanopoulos
ventricular septal defectpost-surgical findings, complications & re-op indications
essentially none
need for re-imagingvirtually none
residual VSD
TOF – PA atresia – PA stenosisProsthetic conduit between subclavian & PA
1962Kilner – refined by Leval
BT shunt ipsilateral to the aortic archLaks and CastanedaLaks and Castaneda
DAo to PA shunt1946 – Potts
Central aortopulmonary shunt1955 – Davidson
AAo to PA shunt1962 – Waterston
in uteroblood flow is supplied to the
lungs via the ductus arteriosus
TOF – PA atresia – PA stenosis
post natalpulmonary vascular resistance is high
requires arterial pressure to perfuse the lungs
ductus arteriosus closes . . . or . . . maintained opened with PGE
commonly used temporary shuntdesigned to palliate low pulmonary blood flow ( TOF, PA atresia) directs arterial blood flow from a subclavian artery to pulmonary arteries
used to augment PA blood flow while
developed for ‘blue babies’1945Blalock & Taussig (& Thomas)Johns Hopkins
Blalock-Taussig shunt – classic
TOFtricuspid atresia
DORV
other singleventricle
physiology
PA pressures transition from elevated perinatal pressure to normal
commonly used temporary shuntdesigned to palliate low pulmonary blood flow directs arterial blood flow from a subclavian artery to pulmonary arteries
used to augment PA blood flow while
Blalock-Taussig shunt – modified
developed for ‘blue babies’1945Blalock & Taussig (& Thomas)Johns Hopkins
TOFtricuspid atresiaDORV
other single ventricle physiology
PA pressures transition from elevated perinatal pressure to normal
x
trans-annular patchaugmentation of the RVOT & enlargement of the MPA
1986 – Kirklin
surgical complications inadequate relief of obstructionpulmonary insufficiency
trans-annular patch
need for re-imagingrestenosis of RVOTbranch PA stenosisRV failure due to PI
Hypoplastic left heart syndromeall left sided structures are small
mitral valveleft ventricleaortic valve
RPA – AAo anastomosis1970Cayler
Multiple modifications of this anastomosis1977 – 1981
ascending aorta
coronary artery perfusion is via retrograde flow from the ductus arteriosus through the ascending aorta
1977 1981DotyLevitskyBehrendtNorwood
Stage 1 – proceeding to successful Fontan1983Norwood – Children’s Hospital Boston
staged surgical procedures toward goal of Fontan circulationpalliation of HLHS
neo-aorta & BT shunt are createdanastomosis of MPA to AAolimit pulmonary blood flow
HLHS – staged repair
ASD – created or enlargedarterial pressure to the lungs
bidirectional cavo-pulmonary shuntvenous pressure to lungs
Fontan circuitcompleted circuit delivers SVC & IVC blood flow to the lungs
Sano shunt2003
Distal MPA is separated from the heart
MPA is used to create neo-aortashunt between the systemic RV and the PAs
Norwood procedure – alternatives
Hybrid procedureAkintuerk – 2002
2004 – Bacha & HijaziPA bands – regulate pulmonary blood flowStent maintains patent ductus arteriosusASD is made or enlarged
permanent shuntintended to palliate hypoplasia of
R sided structures
il t l
Glenn shuntcirculatory bypass of the R heart
1958Glenn – Yale
unilateral
bilateral
bidirectional
used to augment PA blood flow
after PA pressures have normalized
Glenn shuntpost-surgical findings, complications & re-op indications• thrombosis
need for re-imaging• confirming patency• assessment of
pulmonary blood flow
Variation on the Norwood Stage 1
Anastomosis of AAo & MPA & RV to PA conduit1975 – Damus1975 – Kaye1975 – Stansel
Damus – Kaye – Stansel
Variation on the Norwood Stage 1 anastomosis of the hypoplastic ascending aorta to the native MPA
correction of TGA with single ventricle physiology – or
single ventricle repair – HLHS
the MPA is transected and
Damus – Kaye – Stansel
anastomosed with the AAo
post-surgical findings, complications & re-op indications• thrombosis
need for re-imaging
Damus – Kaye – Stansel
• confirming patencyof DKS anastomosis and coronary arteries
• patency of BT & Glenn shunts
Multi-staged procedure to palliate tricuspid atresia, single ventricle syndromes [HLHS, HRV with PA atresia]
total cavopulmonary connection
returns systemic venous
Fontan circulationSuperior and inferior vena cavae anastomosis to the PAs
1971Fontan – University of Bordeaux
returns systemic venous blood flow to the lungs separate from right heart contractions
The R & L circulations are separate
Fontan circulationpost-surgical findings, complications & re-op indications• thrombosis • pleural effusions• ascites
need for re-imaging• confirming patency• assessment of
pulmonary blood flow
D – TGA AV concordance
VA discordance
parallel circulations
Transpositionof the great arteries
prequires mixing - shunt
L – TGA AV discordance
VA discordance
2 wrongs do not make a right
Correction of D loop TGA at the arterial level physiological correction of TGA the aorta and MPA are switches
and the coronary arteries are
i l d i h
Jatene arterial switchArterial switch operation
1975 – Jatene
AP window & baffling to the coronary arteries
1978 – Aubertreimplanted into the neo aorta
Translocation of aortic root including coronary origins
1980 – Bex
correction of D loop TGA at the arterial level
physiological correction of D-TGA
Jatene arterial switch
the aorta and MPA are switched and the coronary arteries are
reimplanted into the neo aorta
Jatene arterial switchpost-surgical findings, complications & re-op indications• tension on great vessels &
reimplanted coronary arteries
need for re-imaging• coronary artery origin stenosis• RV failure as it is not well suited
to be the systemic ventricle
maneuver to minimize kinking of the coronary arteries which
can be a complication of the
arterial switch Jatene procedure
pulmonary arteries are
d d th AA
Le Compte maneuvertransfer of PAs anterior to the AAo
1981Le Compte – Institute of Research & Surgery
draped over the AAo
correction of TGA with VSD and LVOT obstruction
RV – PA conduit is also used for PA atresia TOF
Rastelli procedureMPA is ligated and anastomosed to the RV
1969 – Rastelli
used for PA atresia, TOF,DORV, or HLHS
bovine pericardial conduit or artificial graft material from the RV to the PAstunnel connecting the LV to the aorta
1988 – Borromee
post-surgical findings, complications & re-op indications• thrombosis • pleural effusions• ascites
Rastelli procedure
need for re-imaging• conduit stenosis • pulmonary insufficiency• RV hypertrophy & failure
D or L transposition
obstructed aortic outflow – AV or subaortic stenosis
decreases PA blood flow
protects the pulmonary vascular bed
circumference of band (mm) = child’s weight (kg) + 20Trusler & Mustard
PA banding
protects the pulmonary vascular bed
correction of D-TGA at the atrial level
intra-atrial baffle directs pulmonary venous return to the systemic ventricle
Mustard or Senning – atrial switch
interatrial baffle1954 – Mustardusing artificial pericardium
& systemic venous return to the right ventricle
disadvantage –leaves the RV to supply the systemic circulation
1959 – Senningusing atrial tissue
Physiologic correction of congenitally corrected L-TGA
double switch
Senning or Mustard
& Jatene or Rastelli
Ross procedureUsed to treat aortic stenosisPulmonic valve moved to the aortic position
1962 – Ross Guys Hospital – London
may include replacement of a portion of the AAo
coronary arteries are transferred
cadaveric homograft is used to replace the native pulmonic valve
Coarctation of the aortafirst surgical repair of coarctation of the aorta
1944 Crafoord – Karolinska Institute
End – to – end anastomosismost often performed during the first year of life tissues are more elasticso bringing ends together easier
Coarctation of the aorta – surgical
may be an oblique anastomosis
Patch repair performed at any age
Interventional – catheter based repair
angioplasty & stenting to dilate
coarctation of the aorta
Coarctation of the aorta – stent
beware of
jailing
of the left
subclavian
artery origin
used to palliate interrupted aortic arch
OR
t l t i d
Aorto-aorto bypass graft
to supplement repaired
coarctation of the aorta
not currently performedaugments pulmonary arterial blood flow
sometimes excessively so
Waterston & Potts shunts
Waterston shunt
AAo – RPA
Pott’s shunt
DAo - LPA
Repair of aortic coarctation
Left subclavian artery is ligated
and used to augment the stenotic aorta
Waldhausen procedure
Complicationsreduced blood flow to the left upper extremity
poor growth of the extremity
no longer used
CommonSurgical Procedures
forCongenital
Heart DiseaseHeart Disease
Dianna M. E. Bardo, M. D. Director of Cardiac Radiology
Associate Professor of Radiology,Pediatrics, & Cardiovascular Medicine
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