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Transcript
Common
Cardiac Surgeries
Disclosure
in
Children
Dianna M. E. Bardo, M. D.
Consultant & Speakers Bureau – honoraria
Director of Cardiac Radiology
Associate Professor of Radiology,
Pediatrics, & Cardiovascular Medicine
Koninklijke Philips Healthcare
definitions & a reality check
normal cardiac circulation
Malformation
the right and left sides are normally separate circulations
A primary structural defect arising from a localized error in morphogenesis
- results in the abnormal formation of an organ
separated by the pulmonary capillary bed
intracardiac &
extracardiac
t
di shunts
h t
Dysplasia
Refers to an abnormal organization
g
of cells into tissues
- results in abnormal tissues
The distinction of malformation from dysplasia is at best blurry – there is much overlap
repair
complete anatomic correction of congenital heart defect
palliation
provides physiologic correction of blood flow
in utero – 2 normal shunts
foramen ovale
ductus arteriosus
postnatal abnormal shunts
ASD
VSD
truncus arteriosus
PDA
patent ductus arteriosus
patent ductus arteriosus
division & over-sewing
Performed when he was Chief Resident
& his surgical chairman was out of town!
1938
Gross – Children’s Hospital Boston
post-surgical findings, complications & re-op indications
essentially none
need for re-imaging
virtually none
triple ligation technique
1946
Blalock – Johns Hopkins
pharmacologic closure
indomethacin
1976
Heymann
Catheter based
coil or device closure
1993
atrial septal defect
atrial septal defect
patent
closed technique
foramen ovale
post-surgical findings, complications & re-op indications
essentially none
lateas1940s
earlypressures
1950s
closes
right &heart
increase postnatally
Bailey & Sondergaard (separately)
open repair technique
primum1952
– AVSD
Gross – Children
Children’ss Hospital Boston
direct visualization
1953 – Lewis & Taufic
secundum
using cardiopulmonary bypass
1954 – Gibbons
need for re-imaging
virtually none
residual ASD
sinus venosus
Catheter based
device closure
1997 – Matsura
ventricular septal defect
ventricular septal defect
PAbanding
– palliation of VSD
membranous
1952 – Muller & Dammann
 paramembranous
VSD
closure
1954 – Lillehei – U of Minnesota
 muscular
using a heart-lung machine
1955 – Kirklin – Mayo Clinic
 singleclosure
transatrial
1958 –Stirling
 multiple
total circulatory arrest
1969 – Okamoto
 spontaneous
deep
hypothermia & closure
arrest
Barratt-Boyes
Amplatz closure device
 surgical
& instrumented closure
1999 - Thanopoulos
post-surgical findings, complications & re-op indications
essentially none
TOF – PA atresia – PA stenosis
TOF – PA atresia – PA stenosis
Prosthetic conduit between subclavian & PA
1962
Kilner – refined by Leval
need for re-imaging
virtually none
residual VSD
in utero
blood flow is supplied to the
lungs via the ductus arteriosus
BT shunt ipsilateral to the aortic arch
Laks and Castaneda
DAo to PA shunt
1946 – Potts
Central aortopulmonary shunt
1955 – Davidson
AAo to PA shunt
1962 – Waterston
post natal
pulmonary vascular resistance is high
requires arterial pressure to perfuse the lungs
ductus arteriosus closes . . . or . . . maintained opened with PGE
Blalock-Taussig shunt – classic
Blalock-Taussig shunt – modified
commonly
used
developed for
‘bluetemporary
babies’ shunt
commonly
used
developed for
‘bluetemporary
babies’ shunt
1945to palliate low pulmonary blood flow ( TOF, PA atresia)
designed
Taussig
Thomas)
directsBlalock
arterial&blood
flow(&from
a subclavian artery to pulmonary arteries
Johns Hopkins
used to augment PA blood flow while
PA pressures transition from elevated
perinatal pressure to normal
TOF
tricuspid atresia
DORV
other single
ventricle
physiology
1945to palliate low pulmonary blood flow
designed
Taussig
Thomas)
directsBlalock
arterial&blood
flow(&from
a subclavian artery to pulmonary arteries
Johns Hopkins
used to augment PA blood flow while
PA pressures transition from elevated
perinatal pressure to normal
TOF
tricuspid atresia
DORV
other single ventricle physiology
trans-annular patch
trans-annular patch
xaugmentation of the RVOT &
surgical complications
inadequate relief of obstruction
pulmonary insufficiency
enlargement of the MPA
1986 – Kirklin
need for re-imaging
restenosis of
RVOT
branch PA stenosis
RV failure due to PI
Hypoplastic left heart syndrome
HLHS – staged repair
all
sided
structures are small
RPAleft
– AAo
anastomosis
1970
mitral valve
Cayler
left ventricle
Multiple
of this anastomosis
aorticmodifications
valve
1977 – 1981
ascending
aorta
Doty
staged surgical procedures toward goal of Fontan circulation
palliation of HLHS
Levitsky
Behrendt
coronary
artery perfusion is
Norwood
via retrograde flow from the
Stage 1 – proceeding to successful Fontan
ductus
arteriosus through
1983
the ascending
Norwood – aorta
Children’s Hospital Boston
neo-aorta & BT shunt are created
anastomosis of MPA to AAo
limit pulmonary blood flow
ASD – created or enlarged
arterial pressure to the lungs
bidirectional cavo-pulmonary shunt
venous pressure to lungs
Fontan circuit
completed circuit delivers
SVC & IVC blood flow to the lungs
Norwood procedure – alternatives
Glenn shunt
Sano shunt
2003
permanent
shunt
circulatory bypass
of the R heart
Distal MPA is separated from the heart
MPA is used to create neo-aorta
shunt between the systemic RV and the PAs
Hybrid procedure
Akintuerk – 2002
2004 – Bacha & Hijazi
PA bands – regulate pulmonary blood flow
Stent maintains patent ductus arteriosus
ASD is made or enlarged
Glenn shunt
post-surgical findings, complications & re-op indications
• thrombosis
need for re-imaging
• confirming patency
• assessment of
1958to palliate hypoplasia of
intended
Glenn – Yale
R sided structures
unilateral
il t l
bilateral
bidirectional
used to augment PA blood flow
after PA pressures have normalized
Damus – Kaye – Stansel
Anastomosis of AAo & MPA & RV to PA conduit
1975 – Damus
1975 – Kaye
1975 – Stansel
Variation on the Norwood Stage 1
anastomosis of the hypoplastic
ascending aorta to the native MPA
pulmonary blood flow
Damus – Kaye – Stansel
Damus – Kaye – Stansel
correction of TGA with single ventricle physiology – or
single ventricle repair – HLHS
post-surgical findings, complications & re-op indications
• thrombosis
the MPA is transected and
anastomosed with the AAo
need for re-imaging
• confirming patency
of DKS anastomosis
and coronary arteries
• patency of BT &
Glenn shunts
Fontan circulation
Fontan circulation
Multi-staged
procedure
to palliate tricuspid atresia, single
Superior and inferior
vena cavae
anastomosis
to the PAs [HLHS, HRV with PA atresia]
ventricle syndromes
1971
total cavopulmonary
connection
post-surgical findings, complications & re-op indications
• thrombosis
• pleural effusions
• ascites
Fontan – University of Bordeaux
returns systemic venous
blood flow to the lungs
separate from right heart
contractions
The R & L circulations are separate
Transposition of the great arteries
D – TGA
AV concordance
VA discordance
p
parallel
circulations
requires mixing - shunt
L – TGA
AV discordance
VA discordance
need for re-imaging
• confirming patency
• assessment of
pulmonary blood flow
Jatene arterial switch
Arterial switch operation
1975 – Jatene of
 Correction
D loop TGA at the arterial level
 physiological correction of TGA
AP window
& baffling
to MPA are switches
 the
aorta and
the coronary
arteries
and
the coronary arteries are
1978 – Aubert
reimplanted
i l
d iinto the
h neo aorta
Translocation of aortic root including
coronary origins
1980 – Bex
2 wrongs do not make a right
Jatene arterial switch
Jatene arterial switch
correction of D loop TGA at the arterial level
post-surgical findings, complications & re-op indications
• tension on great vessels &
reimplanted coronary arteries
physiological correction of D-TGA
the aorta and MPA are switched
and the coronary arteries are
reimplanted into the neo aorta
need for re-imaging
• coronary artery origin stenosis
• RV failure as it is not well suited
to be the systemic ventricle
Le Compte maneuver
Rastelli procedure
transfer
of PAs
to the
AAo
maneuver
toanterior
minimize
kinking
1981
– Institute
can beLea Compte
complication
ofofthe
Research & Surgery
MPA is ligatedof
and
anastomosed
to the RV
correction
TGA
with VSD
1969 – Rastelli
and LVOT obstruction
of the coronary arteries which
arterial switch Jatene procedure
pulmonary arteries are
ddrapedd over th
the AA
AAo
RV – PA conduit is also
used for PA atresia,
atresia TOF,
TOF
DORV, or HLHS
bovine pericardial conduit or
tunnel connecting
the LV to from
the aorta
artificial
graft material
– Borromee
the RV1988
to the
PAs
Rastelli procedure
post-surgical findings, complications & re-op indications
• thrombosis
• pleural effusions
• ascites
PA banding
circumference
 D or Lof
transposition
band (mm) = child’s weight (kg) + 20
Trusler
& Mustardaortic outflow – AV or subaortic stenosis
 obstructed
 decreases PA blood flow
 protects the pulmonary vascular bed
need for re-imaging
• conduit stenosis
• pulmonary insufficiency
• RV hypertrophy & failure
Mustard or Senning – atrial switch
correction
of D-TGA at the atrial
interatrial
baffle
1954 – Mustard
using
artificial
intra-atrial
baffle
pericardium
directs
pulmonary venous return
level
double switch
Physiologic correction of
congenitally corrected
L-TGA
to the systemic ventricle
& systemic venous return
to the right ventricle
disadvantage –
leaves
the–RV
to supply the
1959
Senning
systemic
using circulation
atrial tissue
Senning or Mustard
& Jatene or Rastelli
Ross procedure
Coarctation of the aorta
Used to valve
treatmoved to the
Pulmonic
aortic
position
aortic stenosis
1962 – Ross
Guys Hospital – London
first surgical repair of
coarctation of the aorta
1944
Crafoord – Karolinska Institute
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 aorta – surgical
Coarctation of the aorta – stent
End – to – end anastomosis
Interventional – catheter based repair
most often performed during the first year of life
tissues are more elastic
so bringing ends together easier
may be an oblique anastomosis
Patch repair
performed at any age
Aorto-aorto bypass graft
used to palliate interrupted aortic arch
OR
tto supplement
l
t repaired
i d
coarctation of the aorta
angioplasty & stenting to dilate
coarctation of the aorta
beware of
jailing
of the left
subclavian
artery origin
Waterston & Potts shunts
not currently performed
augments pulmonary arterial blood flow
sometimes excessively so
Waterston shunt
AAo – RPA
Pott’s shunt
DAo - LPA
Waldhausen procedure
Repair of aortic coarctation
Left subclavian artery is ligated
and used to augment the stenotic aorta
Complications
reduced blood flow to the left upper extremity
poor growth of the extremity
no longer used
Common
Surgical Procedures
for
Congenital
Heart Disease
Dianna M. E. Bardo, M. D.
Director of Cardiac Radiology
Associate Professor of Radiology,
Pediatrics, & Cardiovascular Medicine