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Peds Cardiology > 12. Surgery > Flashcards

12. Surgery Flashcards

1
Q

Where does the AV node sit in relation to a membranous VSD?

A

Posterior-inferior rim

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2
Q

What can cause high-grade AV block after membranous VSD repair?

A

Damage to AV node

*Possibly a suture in the posterior-inferior rim too close to AV node

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3
Q

True or false: Secundum ASD repair increases risk for AV block

A

False

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4
Q

Ascending aorta to PA shunt?

A

Waterston

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5
Q

Descending aorta to LPA shunt?

A

Potts

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6
Q

Why are Waterston or Potts shunts rarely done?

A

Hard to regulate size (too big can lead to pulm HTN + PVOD)

High rate branch PS

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7
Q

What do inappropriately large AP shunts have risk for?

A
  1. Pulmonary HTN

2. PVOD

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8
Q

What types of AP shunts can result in a more predictable shunt volume?

A
  1. Central shunt
  2. Modified BTT shunt

*Synthetic shunt that is a specific size

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9
Q

What is a classic BTT shunt?

A

Direct connection to left or right subclavian artery to ipsilateral branch PA

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10
Q

Why are classic BTT shunts no longer preferred?

A

Frequent shunt obstruction

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11
Q

What effect does severe PS have on risk for PVOD?

A

Protects the pulmonary vascular bed and decreases risk of pulmonary vascular disease

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12
Q

Most common indication to late reoperation after complete AVSD repair?

A

Left AVVR

*Uncommon indications: Small residual atrial/ventricular shunts, right AVVR

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13
Q

What % of AVSD patients have a need for late reoperation?

A

15-20%

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14
Q

In which type of AVSD is LVOTO a frequent indication for reoperation?

A

Partial

*LVOTO is infrequent indication for reoperation in complete AVSD

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15
Q

Strongest predictor for developing MR after repair of AVSD?

A

Pre-operative severe MR

*LV size/hemodynamics can influence this, but not as strong of association

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16
Q

True or False: The degree of cleft in the left AV valve is a predictor of post-operative left AVVR

A

False: Cleft in left AV valve is universal - doesn’t predict post-op regurgitation

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17
Q

Does the need for an annuloplasty ring in repair of left AV valve in AVSD predict post-op regurgitation?

A

No - It doesn’t independently predict post-op regurgitation

*It may reflect the degree of pre-op regurgitation (which is strongest predictor for MR after AVSD repair)

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18
Q

What index is used to predict operability in PA-VSD?

A

Nakata

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19
Q

Equation for Nakata index?

A

LPA area + RPA area + MAPCA area/BSA

*Measure PAs just proximal to 1st lobar branch, include MACPAs that perfuse an entire lung segment and could be unifocalized

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20
Q

Patients with a Nakata over what are considered to be a good candidate for complete repair (including potential unifocalization)?

A

200

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21
Q

Patients with a Nakata under 200 are at increased risk for what with complete repair?

A

Pulmonary HTN and right heart failure

*No intervention or limited surgical palliation may be better option

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22
Q

What should you consider for a patient s/p aortic valve replacement with complete heart block post-op?

A

Compromised coronary artery perfusion

*Can get compression of coronary by valve, transection of coronary or tension/kinking with reimplantation

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23
Q

Post-op heart block
ST segment changes
Ventricular dysfunction

A

Possible compromised coronary artery perfusion

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24
Q

How do you definitively identify a compromised coronary artery?

A

Angiography

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25
Q

What supplies the AV node in most people?

A

Branch of RCA

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26
Q

Fontan with DOE and cyanosis that is worse in standing position… cause?

A

Pulmonary AVM

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27
Q

What 2 things can cause DOE and orthostatic or exertional cyanosis in Fontan patients?

A
  1. R-L shunting at a fenestration

2. R-L shunting from pulmonary AVMs

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28
Q

Most common location for a pulmonary AVM in a Fontan patient?

A

Basal region

*Why cyanosis is worse with standing v. supine

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29
Q

What EP issue are patients s/p Atrial switch (Mustard) at high risk for?

A

Sinus node dysfunction

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30
Q

Where is the sinus node located?

A

Posterior RA along superior-lateral aspect of SVC

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31
Q

Why is sinus node dysfunction seen in atrial switch patients?

A

In the Mustard/Senning a patch baffle is sutured along the posterior (sinus venosus) wall of the RA to direct systemic venous return across the atrial septum to the left sided subpulmonary ventricle… this is very close proximity to sinus node with risk for damage (surgical disruption of that area)

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32
Q

What are the components of a Stage I hybrid procedure?

A
  1. Band PAs

2. Stent PDA (interventionalist does this)

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33
Q

How does a hybrid procedure minimize risk as a stage 1 option?

A

Doesn’t require CP bypass or circulatory arrest… this minimizes risk and may reduce early-stage mortality in high risk neonates

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34
Q

What would cause progressive left heart distention in a ToF + PA patient after initiation of CP bypass using bicaval and aortic vannulation?

A

AP collaterals

*Persistent pulmonary blood flow returning to LA not accounted for in bypass circuit

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35
Q

If the aorta isn’t cross-clamped going onto bypass, what could cause LV distention?

A

Significant AI

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36
Q

During bypass, what would a persistent left SVC cause?

A

RV distention… the persistent left SVC drains to the CS and blood returns to the RA

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37
Q

Most common cause of reoperation in partial AVSD?

A

MR

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38
Q

Cause of reoperation for AVSD patients which is more common in partial AVSD versus complete AVSD?

A

LVOTO

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39
Q

SOB, cardiomegaly and increased pulmonary vascularity in a repaired AVSD should make you consider what 2 things?

A
  1. MR

2. LVOTO

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40
Q

In a repaired partial AVSD, what should an ejection-type systolic murmur that diminishes with Valsalva make you consider?

A

LVOTO

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41
Q

In primary pulmonary HTN, what would you expect to see on CXR?

A

Diminished pulmonary vascularity

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42
Q

Harsh 4/6 systolic murmur months following bypass surgery with no clear valvular problems, but increased gradient in ascending aorta?

A

Aortic cannulation injury

*Get narrowing in the aorta where it was cannulated for CP bypass

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43
Q

When does ALCAPA usually present?

A

2-3 months

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44
Q

Why does ALCAPA present at 2-3 months?

A

When PVR falls, the anomalous coronary artery loses perfusion pressure

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45
Q

What will echo show in ALCAPA?

A

Dilated LV with poor function (due to myocardial ischemia from anomalous coronary)

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46
Q

Why would a patient with ALCAPA have MR?

A

Risk for ischemia/infarction of the mitral valve papillary muscles

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47
Q

What normally perfuses the tricuspid valve papillary muscles?

A

Branches of RCA

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48
Q

In ALCAPA what pre-op finding is most closely associated with post-op mortality and need for late reoperation?

A

MR

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49
Q

What is the most common long-term complication in patients with repaired Scimitar?

A

Pulmonary vein obstruction

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50
Q

What is Scimitar syndrome?

A

Anomalous right pulmonary veins connecting to IVC

51
Q

What 2 things is the surgical repair in Scimitar dependent on?

A
  1. Proximity of anomalous venous connection to RA

2. Presence of ASD

52
Q

How is Scimitar repaired?

A
  1. Anomalous connection transected
  2. Right veins reimplanted to RA or LA
  3. If implanted to RA, right pulmonary venous return is directed across ASD into LA by patch baffle
53
Q

Interrupted IVC patient s/p Glenn who has become desaturated… what is likely cause?

A

Intrapulmonary shunting

54
Q

Why is the development of pulmonary AVMs a risk with Glenn (classic cavopulmonary anastomosis)?

A

Lack of hepatic effluent in blood flow to lungs

55
Q

What should be done for a desaturated Glenn with interrupted IVC?

A

Hepatic vein incorporation (higher risk for development of pulmonary AVMs without hepatic factor)

56
Q

What is a classic Fontan?

A

Direct RA-PA anastomosis

57
Q

What is a modified Fontan?

A

Extracardiac conduit or lateral tunnel

58
Q

Patient with a classic Glenn who is desaturated and cath has low sat in RLPV… possible cause?

A

AVMs in right lung

59
Q

What is a risk with the classic cavopulmonary anastomosis (Glenn)?

A

Development of AVMs

60
Q

What is a classic Glenn?

A

Direct end-to-end anastomosis of SVC to RPA

61
Q

What is missing in the pulmonary circulation in Glenn physiology?

A

Hepatic factor (effluent)

*HF prevents the development of AV fistulae

62
Q

True or False: Incorporation of hepatic venous return to the pulmonary circulation can resolve pulmonary PVMs and improve saturations?

A

True

63
Q

What is a DKS anastomosis

A

Connection of ascending aorta to MPA (end-to-side)

*Used with single-ventricle/LVOTO and allows for retrograde perfusion of coronaries via a reconstructed “neo-aortic” arch

64
Q

Why is surgical enlargement of the VSD not used in tricuspid atresia with D-TGA?

A

Risks damage to conduction system causing rhythm disturbance and ventricular dysfunction

65
Q

Which type of PV intervention produces better relief of stenosis, but often a greater degree of regurgitation?

A

Percutaneous (versus surgical)

66
Q

If there is a good initial outcome after surgical valvotomy for the pulmonary valve, what is the risk of need for future reoperation?

A

Likely <5% over 10 years

67
Q

What are features that make someone with PA-IVS not a candidate for 2V repair?

A
  • RV hypoplasia
  • TV annulus Z-score <3
  • Coronary to RV fistulae
68
Q

What are some features that make someone with PA-IVS a candidate for 2V repair?

A
  • Reasonable RV size, tripartite
  • TV Z-score -2 to -2.5
  • Functional TV
  • No coronary-cameral fistulas (RV dependent coronary circulation)
69
Q

What needs done for an infant with PA-IVS and a small RV with coronary-cameral fisulae?

A

BTT shunt

70
Q

Why can’t you decompress a RV in someone with PA-IVS and coronary cameral fisulae?

A

Decreases coronary perfusion pressure resulting in diffuse myocardial ischemia

71
Q

Successful outcome after complete repair of PA + VSD correlates with what?

A

Post-operative RVSP

72
Q

What should be done after coming off bypass for a complete repair of PA+VSD if there is poor systemic BP and near systemic RVSP?

A

Re-open VSD

  • Limited CO due to increase PVR with VSD closed, VSD allows a pop-off
  • Patients may need palliation v. complete repair
73
Q

What is preferred surgical approach for truncus arteriosus?

A
  • Early complete repair within 1st month of life

- Delaying intervention increases risk for irreversible pulmonary vascular obstructive disease

74
Q

Most common indication for reoperation in a patient with a history of truncus arteriosus?

A

RV-PA conduit failure

Other Potentials: Neo-aortic valve regurgitation, neo-aortic valve stenosis, RV-PA conduit failure, residual VSD, branch PA stenosis

75
Q

How long to homograft or synthetic conduits tend to last?

A

10-15 years

*Almost always become stenotic and/or regurgitant

76
Q

What is more common in truncus, neo-aortic valve regurgitation or neo-aortic valve stenosis?

A

-Regurgitation: Can often be managed without surgical intervention until mod-severe

77
Q

CoA in 1 y/o with LA 117/79 and LL 99/70, bicuspid Ao valve, mild AI, mild AscAo dilation, normal LV function, LV wall thickness upper limits of normal. Strongest reason for surgery?

A

BP

-Systemic HTN + Mild gradient + CoA = Surgical treatment

78
Q

What are 2 ways to measure severity of CoA?

A
  • Anatomically (estimated Doppler gradient)

- Non-invasive BP

79
Q

If the SBP gradient is <20mmHg, what are other factors which may push to surgery for CoA?

A
  1. Systemic HTN
  2. LV dysfunction
  3. Significant collateral arteries
80
Q

In HLHS, when is the highest risk of mortality?

A

Between stage 1 and stage 1

81
Q

Describe the 3 stages for single ventricle palliation for HLHS

A

1: Excision of any remaining atrial septal tissue, separation of PAs from MPA trunk, BTT shunt to branch PAs, construction of neo-aortic arch using MPA tissue
- RV is systemic ventricle and pulmonary valve functions as the systemic (neo-aortic) valve
- Usually done in 1st week of life in term neonates without comorbidities
2: Takedown of BT shunt and placement of an SVC to PA anastomosis (bidirectional cavopulmonary anastomosis)
- Typically occurs around 6-9 months (depending on growth and cyanosis)
3: Anastomosis of IVC to PAs via extracardiac conduit or lateral tunnel along the lateral wall of the RA (modified Fontan)
- Can be done as early as 2 years

82
Q

What could cause progressive cyanosis, mild metabolic acidosis, mild hypotension, tachypnea, increased pulmonary vascular markings in a neonate shortly after hybrid Norwood palliation?

A

Restrictive ASD

*Pulmonary congestion from pulmonary venous obstruction… only way for pulmonary venous return to reach systemic circulation is via ASD

83
Q

After a hybrid Norwood palliation, how would retrograde aortic arch obstruction from the PDA stent present?

A
  • Coronary hypoperfusion

- Decreased ventricular function

84
Q

After a hybrid Norwood palliation, how would obstruction of the branch PAs present?

A
  • Decreased saturations

- Clear lung fields

85
Q

What is the goal of stage 1 surgical palliation (Norwood) for HLHS?

A

Relief of ductal-dependent systemic blood flow

  • HLHS = No LV output so systemic blood flow is from RV via PDA
  • Goal is to establish stable systemic blood flow
86
Q

What is the most common indication for re-operation after ASO in D-TGA?

A

Supravalvar PS

87
Q

What is the repair of choice for D-TGA?

A

ASO (over atrial switch)

88
Q

What 2 things are complications of the ASO primarily related to?

A
  • Mobilization and relocation of the great arteries and coronaries
  • Coronary issues have a higher mortality risk, but supravalvar PS is more common
89
Q

Why is the LeCompte used with ASO?

A
  • In D-TGA< the aorta is anterior to the PA
  • Relocating the PA anterior introduces a risk of supravalvar stenosis (the artery is stretched behind the ascending aorta)
  • In the LeCompte, you transect the MPA and relocate the entire PA trunk and bifurcation anterior
90
Q

What needs considered in a neonate with regional dysfunction post ASO?

A

Coronary artery obstruction leading to myocardial ischemia

91
Q

d-TGA with a nonrestrictive VSD, but severe PS and hypoxia… what should be done?

A

BTT shunt

-Inadequate pulmonary blood flow

92
Q

L-TGA with a large VSD (membranous with outlet extension), critical PS s/p BTT and now Glenn. Good biventricular size and function, AVV function well… surgical options?

A

-Close VSD directing morphologic LV flow across VSD to AoV, RV-PA conduit, Baffle IVC to tricuspid valve

93
Q

DORV, normally related great arteries, large doubly-committed VSD, severe CoA, mild subaortic stenosis, straddling mitral valve… surgical approach?

A
  • Norwood/Sano, CoA repair (because of straddling MV)

* If no straddling valve, could repair VSD/CoA and resect subaortic stenosis

94
Q

What is an advantage of Sano over BTT?

A

Sano has pulsatile flow which may promote better growth of branch PAs

95
Q

Describe Taussig-Bing physiology

A
  • Form of DORV with VSD being sub-pulmonary
  • Physiology similar to transposition: PA getting saturated blood from LV via subpulmonary VSD and aorta is remote from VSD getting desaturated blood from RV
96
Q

What is the recommended surgical approach for Taussig-Bing?

A

Arterial switch + Baffle closure of VSD to neo-aorta

97
Q

DILV with hypoplastic subaortic RV, restrictive bulboventricular foramen (VSD) and severe subaortic stenosis… initial surgery?

A

DKS + BTT

  • Ao from hypoplastic RV with no inflow: Systemic output dependent on VSD size and LVOT patency (severely compromised here with LVOTO and restrictive VSD)
  • Need stable pulmonary blood flow: BTT
98
Q

When do you need to close an ASD surgically v. in the cath lab?

A
  1. Deficiency of the posterior-inferior septal rim
  2. Presence of coexisting abnormalities that would benefit from surgical repair (specifically mod-severe TR- benefit from annuloplasty or valve repair)
99
Q

What would happen in a Fontan with an anomalous connection of the right lower pulmonary vein to the IVC?

A

Infarction of the right lower lobe of the lung

  • Persistent connection of the anomalous pulmonary vein to the systemic venous circuit = No driving pressure across the the RLPA
  • RLPA pressure = Fontan pressure = RLPV pressure
100
Q

What type of CoA repair has a significant risk for pseudoaneurysm at the site of repair?

A

Synthetic patch repair

101
Q

What kind of repair would you suspect in an ECG with sinus rhythm and RBBB?

A

VSD repair or transannular patch repair (incision of RV wall)

*Pulmonary valvotomy, surgical ASD repair and ASO are done without damage to the RV myocardium

102
Q

What ECG change might you see after a LV septal myectomy?

A

LBBB

103
Q

What is the most frequently recognized post-operative complication after an ASO for d-TGA?

A

SVC baffle obstruction

104
Q

How is an atrial switch (Mustard or Senning) done?

A

Baffle SVC and IVC flow to the left sided AV valve and into the subpulmonary ventricle

105
Q

How does and SVC or IVC baffle obstruction present after an atrial switch?

A
  • Central venous obstruction
  • SVC: JVD, facial edema, increased head size in infants with open fontanelle
  • IVC: Hepatomegaly, ascites, LE edema
106
Q

Which is more common SVC or IVC obstruction after an atrial switch?

A

SVC

107
Q

What are 2 approaches to fixing baffle obstruction after atrial switch?

A
  1. Surgical revision

2. Stent placement in cath lab

108
Q

If another indication for cardiac surgery, what should be done for an anomalous RCA from the left sinus of valsalve?

A

Unroofing intramural segment to enlarge orifice

*Debate if intervention needed if this is only finding in asymptomatic individual

109
Q

Describe the Warden repair for sinus venosus ASD with anomalous RUPV

A

-Transection of the SVC above the insertion of the pulmonary veins
Baffling of the anomalous pulmonary vein/SVC stump to the ASD
-Reimplantation of the upper SVC to RA appendage

110
Q

When is a LeCompte maneuver needed in d-TGA?

A

When there is an anterior-posterior relationship of the semilunar valves

  • When PA is directly posterior to the aorta, switching would cause stenosis of the MPA or RPA
  • LeCompte transects the MPA and relocates the entire PA trunk and bifurcation anterior to the aorta
111
Q

What is the most common indication for reoperation in neonates who have had a Ross?

A

Pulmonary homograft failure

112
Q

What is a Ross?

A
  • Autograft replacement of the stenotic aortic valve with native pulmonary valve
  • Homograft placed in the pulmonary position
113
Q

List risks associated with a Ross

A
  • Arrhythmia
  • Subaortic stenosis
  • Neo-aortic valve failure
  • Coronary artery obstruction
114
Q

What should be done during an Ebstein repair in a patient with a history of SVT?

A

MAZE

115
Q

What is a MAZE?

A

Ablative procedure involving intraoperative cryoablation or RF ablation across several segments in the RA

*Good for supraventricular tachyarrhythmias (A-fib, A-flutter, SVT, etc.)

116
Q

What surgery is typically done for Ebstein with severe RV hypoplasia and significant TR?

A

Starnes

*Done in anticipation of Fontan palliation

117
Q

What is a Starnes procedure?

A
  • Patch occlusion of tricuspid valve at annulus
  • Removal of atrial septum
  • Placement of systemic to PA shunt
118
Q

Immediate post-op neonate who is hypotensive despite fluid and increase in epi and vasopressin, CVP 18, lactate elevated, echo with underfilled ventricles with normal function, no effusion, no thrombus… next step?

A

Open chest

  • Poor perfusion, high CVP, normal function, underfilled ventricles with no effusion… external restriction to filling
  • Peri-operative swelling can increase intrathoracic pressure and restrict diastolic filling… need to open sternotomy to relieve increased intrathoracic pressure
119
Q

What is it called when the LPA arises from the RPA and passes posterior to the bronchi?

A

LPA sling

120
Q

What should be done for an LPA sling?

A

Re-implant LPA anterior to bronchi

*Vessel may need angioplasty or stent if it is hypoplastic

121
Q

Fever + CP in a post-operative patient?

A

Post-pericardiotomy syndrome

122
Q

What surgeries is post-pericardiotomy syndrome more common in?

A

ToF, ASD, VSD

123
Q

What should be given for post-pericardiotomy syndrome?

A
  • High-dose ASA for 4-6 weeks
  • May need steroids if ASA doesn’t help

*No colchicine

124
Q

What other concern needs to be evaluated in post-pericardiotomy syndrome?

A

Endocarditis… get blood cultures

Peds Cardiology (20 decks)

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