Common Cardiac Surgeries Children

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