Congenital Heart Disease Flashcards
What is the percent of live births that have Congenital Heart Disease (CHD) ?
1%
8 in 1000
If untreated, how many of the CHD babies will die within first month?
Die in first year?
1/3 die in first month
1/3 die in first year
Do the remaining patients with CHD die sooner or later than the general population?
Final 1/3 die sooner
What are some Left to Right shunts ?
VSD
ASD
PDA
AV Canal
What are some right to left shunts?
Tetrolagy of fallot
All the ‘blue babies”
What is the most common CHD diagnosis problem?
VSD
about 17%
What 2 diagnoses account for approximately 10% each of CHD?
- -d-transposition of the great arteries
- -Tetralogy of fallot
What are some signs and symptoms of L 2 R shunts?
- -Increased pulmonary blood flow
- -Volume-overloaded ventricles
- -Developed CHF
What are some signs and symptoms of R 2 L shunts?
- -Decreased pulmonary blood flow
- -Pressure-overloaded ventricles
- -Cyanotic (blue babies)
What are some signs and symptoms of pulmonary shunts?
Cyanotic (blue babies)
What will present in patients with known CHD that are unrepaired?
Eisenmenger’s Syndrome (complex)
This will be covered more in depth in next subject
Which CHD is a mixing lesion that presents with variable pressure versus volume loaded ventricles and cyanotic?
Transposition of the Great Arteries (TGA)
When talking about pulmonary flow, what symbol is used?
Qp
When talking about systemic flow, what symbol is used?
Qs
What is defined as normal or repaired?
Means there is no impact on the patients longevity, physical status, or need for further care.
What are some “repaired” CHD?
PDA ligation
Repair of secundum ASD in 1st decade
Non-complex VSD in 1-2 months of birth
What is a VSD?
Ventricular septal defect
There is a hole between chambers of ventricles
In early life of a VSD patient, how and why is blood shunted?
Shunted L –> R
B/c increased SVR pressure and increased LV pressure force blood into RV because it has lower pressure
When does an VSD cause symptoms of congestive heart failure (CHF) to appear?
When Qp becomes more than twice the Qs
this is caused by excess lung blood flow due to pressure gradients with L –> R shunt
How do VSD patients appear?
Skinny
Tachypnea
Sweating when eating
Lots of reoccurring colds
Later in the life of a VSD patient, the shunt is what ?
What disease state does this result in?
R –> L
Eisenmenger’s Syndrome
What is also called an endocardial cushion defect or atrioventricular septal defect?
Atrioventricular canal defect (CAVC)
AV Canal
What kind of shunt occurs in a AV canal defect?
Large L –> R shunt
What patient population is at very high risk for also having an AV canal?
Down’s syndrome
Trisomy 21
How does an AV canal patient present?
- -Elevated PVR
- -Stenotic or insufficient AV valves
- -Possible sleep apnea with Downs
What are 2 main problems / symptoms of an AV canal?
- -Center post (septum) missing
- -4-5 leaflet valve merged over septum
What are 3 main surgical goals of AV canal defect repair?
- -Closing ASD
- -Closing VSD
- -Making 2 AV valves from large one
What are the 4 associated problems that are common in Tetralogy of Fallot (TOF)?
- -VSD
- -Pulmonary stenosis
- -Overriding Aorta
- -RV hypertrophy
What kind of shunt is a TOF?
R –> L
Is the TOF patients repaired or fixed and why?
Fixed but not repaired
B/c eventually RV will fail
What are the surgical treatments / goals of TOF?
- -Close VSD
- -Relieve PS or RV outflow tract obstruction (RVOTO) caused by overriding Aorta
What are the 3 ways the PS or RVOTO can consist of?
- Infundibular (muscular stenosis under valve)
- Valvular stenosis
- Supravalvular (stenosis above valve)
What do the surgical treatments of the RVOTO eventually lead to?
- -Increase in volume work of RV
- RV dilation over time
- Tricuspid Regurg
- Eventual need for surgical replacement of pulmonary valve
What is the transannular patch in the TOF?
A repair in which the pulmonary valve is removed and a “patch” is place that extends directly to the main pulmonary artery.
This results in pulmonary insufficiency (PI)
What condition occurs when the arteries are coming from the wrong ventricle?
Transposition of the Great Arteries (TGA)
Describe blood flow through heart in TGA.
–SVC & IVC –> RA –> RV –> Aorta –> systemic circulation –> SVC & IVC
– Lungs –>Pulmonary veins –> LA –> LV –> Pulmonary arteries –> hopeful patent foramen ovale, VSD, or connecting blood vessel from PA to aorta to deliver some oxygenated blood to systemic system
What 2 surgical procedures make up correcting TGA?
- Atrial Switch Procedure
- - Arterial switch procedure
What is atrial switch procedure?
- -Mustard or Senning procedure
- -Early procedure seen in patients 20 years and older
- Baffling procedure in which systemic venous blood shunted to mitral valve LA and LV and out PA. Meanwhile pulmonary venous blood passed to tricuspid valve RA and RV and out aorta
What are 2 main issues with atrial switch?
- -Supraventricular arrhythmias
- - RV given load of systemic pressure and output and cannot sustain. Develop low CO and need for heart transplantation
What is the arterial switch procedure?
- Jatene procedure
- Seen in younger population
- Aorta becomes PA and connected to main pulmonary arteries and old PA becomes connected with ascending aorta. Must also move coronaries to ‘new aorta”
What is the main problem or achilles heel of the arterial switch procedure?
The transfer of the coronaries
What problems can arise late in the arterial switch procedure?
- -Supravalvular stenosis of aorta or PA
- new Aortic valve insufficiency
- Coronary ostial stenosis from moving coronaries
What does HLHS stand for?
Hypoplastic Left Heart Syndrome
What anatomy can one assume from a patient that has HLHS?
- -Single Ventricle
- Pulmonary atresia
- Tricuspid valve atresia
What is the first thing that surgically happens for HLHS with a right side obstruction?
Blalock-Taussig shunt (BT shunt)
(Shunt from which blood is directed from R subclavian or R carotid arteries directly to PA so get more blood flow to lungs to hopefully correct cyanosis)
What is the first thing that surgically happens for HLHS with a left side obstruction?
Norwood series
What is the Norwood series?
- -Aortic reconstruction with the main PA
- Atrial septosomy (hole created between atria
- BT shunt
For both left side and right side obstructions in patients with HLHS, what is the second surgical procedure?
–Glenn anastomosis
consist of takedown of BT shunt and direct connection of SVC to PA
Why does the second stage of the HLHS procedures have to wait until around 6 months of age?
Because PVR is too high for 1 ventricle doing 1 pump to push blood through lungs via the SVC
For both left side and right side obstructions in patients with HLHS, what is the third surgical procedure?
–Fontan completion
consist of direct connection of IVC to PA resulting in all systemic venous return directly to lungs
For patients with Fontan physiology, what 2 items must be required?
- -Absence of impediments to pulmonary blood flow and low PVR
- Good single ventricle function
How is blood pushed throughout body in Fontan physiology?
Blood pushed through both systemic and pulmonary circulation by one single pump (beat) of single ventricle
When considering anesthetic management of CHD, what is essential to know for initial management?
- -CHD diagnosis
- - Procedures performed to correct / repair the CHD diagnosis
What symptoms will present when patient is in Fontan physiology failure?
Fatigue
Headache
Swelling / Edema
Protein losing enteropathy
Is a cardiology consult “clearance” sufficient enough knowledge to proceed with surgery?
NOT SUFFICIENT
During a case of CHD, what must anesthesia maintain?
- -Maintain ventricular function
- Maintain intravascular volume (not overloaded though)
- Avoid increases in PVR
- Tight pain control
During inhalational induction (particular in peds and CHD), what must you avoid?
Overdose of volatile agent because it will reduce CO which would then lead to difficulty eliminating the agent
For CHD patients, is spontaneous or PPV better?
Good PPV is better than bad Spont
Low lung volumes of air will do what?
Increase PVR
which is bad
According to the 2007 revision of SBE prophylaxis, what cardiac conditions require SBE?
–Prosthetic heart valves
– Previous Infective
– CHD with :
unrepaired cyanotic CHD
Repaired CHD within 6 months
Repaired but with residual defects
– Cardiac transplantation with valvulopathy
What are some procedures that require SBE prophylaxis?
- Dental procedures
- Excessive bleeding
- Infected respiratory tract, skin, muscle, bone procedures
- Adeniodectomy
- Tonsillectomy
- Rigid bronchoscopy
- Surgery through respiratory mucosa
Before penicillin, what was fatality rate of patients that obtained SBE?
100% fatality
To trigger SBE prophylaxis, what two things are needed?
- Susceptible patient
- - At risk procedure
What is the common SBE prophylaxis antibiotic given?
IV Ampicillin 30 min before surgery
Oral amoxicillin 1 hour before surgery
What disease state will produce 2 p waves on the ECG?
Heart transplantation
What drug will not work on the heart because denervation of nerves to heart?
Atropine
anticholinergics in general
What should be avoided when dealing with a heart transplanted patient?
Reversal of NM blockade
neostig will brady heart and glycopyrolate will not fix this
If taking care of a patient who has had a heart transplant, what must be taken into account?
- Immunosuppression
- - Know the activity level of patient to get determination of heart function
