Procedures Flashcards
Palliative procedures are often associated with what CHD
- Severe Tetralogy of Fallot
- Pulmonary atresia
- Hypoplastic right/left heart syndrome
- Extreme prematurity
what are the 3 palliative systemic to pulmonary artery shunts?
Classic Blalock-Taussing (BT) shunt
Potts
Waterston
Modified (BT) shunt
What type of anastomosis is a classic BT shunt?
What vessels are involved?
-End-to-side anastomosis
-subclavian artery and branch pulmonary artery
Classic BT shunt is most commonly used in what CHD?
TOF
What type of anastomosis is the Waterston shunt?
What vessels are involved?
side-to-side anastomosis
between the ascending aorta and right pulmonary artery
no longer commonly performed
What type of anastomosis is the Potts shunt?
What vessels are involved?
side-to-side anastomosis
between descending aorta and left pulmonary artery
no longer commonly performed
modified BT shunt consist of
variation of classic BT utilizing a synthetic Gore-Tex graft connecting the subclavian artery and a branch pulmonary artery
Doppler interrogation of a BT shunt will demonstrate
High-velocity flow profile because is systemic to venous shunt
Below baseline
Best seen in SSN SAX view “above crab view” dumping into the RPA.
What type of anastomosis is a Classic Glenn shunt?
end-to-side anastomosis
end of the RPA to the side of the SVC
Only to the right RPA
Unlike systemic to pulmonary shunts the doppler for a Glenn is
low velocity slightly phasic flow, because venous to venous shunt versus a systemic to venous like BT shunts are
pulmonary artery distortion less likely to occure due to low flow
What type of anastomosis is a bidirectional Glenn shunt
End-to-side anastomosis
between the SVC and branch pulmonary arteries
allows flow to both lungs unlike the Classic glenn
What is SVC syndrome
compression/obstruction of the SVC resulting in increased venous pressure and upper edema
Can be result of Glenn
Post follow-up of a Glenn shunt should look for
- Narrowing at the anastomosis between the SVC and right pulmonary artery
- Assess for thrombus formation in the shunt
- Assess for SVC syndrome
- Eval size of the PA’s
- Doppler will be low velocity, phasic flow from the shunt to the branches.
Pulmonary artery banding is used to
to reduce excessive pulmonary blood flow due to an underlying cardiac defect in setting of large VSD, ASD, Etc.
Pulmonary banding is performed via ___ thoracotomy.
Left thoracotomy
Pulmonary banding doppler profile
similar to severe pulmonary stenosis, very high systolic jet
The intent to having a atrial septectomy is to
improve arterial saturation by encouraging mixing at the atrial level
What are the types of atrial septectomy?
Blalock-Hanlon- not common anymore, requires right thoracotomy
Rashkind balloon septostomy- most common, cath lab, seen with D-TGA, HLHS with restrictive IAS
Park blade septostomy- cath lab, used for thicker atrial septum
Surgical ASD repair
Dacron Patch- surgically closed, becoming less common due to advent device closures, can wait till pt symptomatic, discharged in 4 days
When is a VSD repair necessary?
When the patient becomes symptomatic and has signs of HF and failure to thrive. Can cause surgically created AV block.
most closed with patch material, newer technique involves closing muscular VSDs with device in Cath lab
Primary indication for AVSD repair
PHTN and HF/failure to thrive
Around what age does AVSD repair typically begin?
between 3-6months of age
AVSD surgical repair involves?
- patch closure of septal defects
- suture closure of the MV cleft
Risk factors of AVSD repairs?
- Residual MR- further repair/replacement
- Subaortic stenosis due to atrioventricular valve tissue -more common in partial AVSD repair
AVSD preop echo should assess?
Type of AVSD
identify AV valve type (Rastelli)
Assess left AV valve anatomy
Eval AV valve regurgitation
optain on foss view of MV in Subcx
Tetralogy of Fallot repair
goal is to resection right ventricular muscle bundles responsible for sub-pulmonary stenosis
VSD closure
Establish pulmonary outflow Via: pulmonary artery augmentation
Transannular patch
Conduit placement
Pre-op exam for Tetralogy of Fallot should assess
- Levels of PS
- Coronary artery origin (aware of conal coronary branching across the right ventricular outflow tract that could affect transannular patch repair)
- Assess branch pulmonary arteries for stenosis
- Size and location of VSD
- Assess arch sidedness (right arch is very common in TOF)
Post Tetralogy of Fallot repairs are at risk for?
severe PI (most common)
residual VSD
surgical AV block
AI from root dilation
Rastelli is usually used to repair?
DORV
D-TGA with VSD
truncus arteriosus
Rastelli procedure involves?
creating a tunnel by using a patch, connecting the left ventricle to the aorta and effectively closing the VSD.
Risk for conduit stenosis, and pulmonary insufficiency
Rastelli post-op echo should look for?
conduit stenosis
residual VSD leak
eval conduit for pseudoaneurysm or thrombus
pulmonary insufficiency
two different approaches to repair of D-TGA
- Senning or mustard procedure (not commonly used today)
- Arterial switch
Sennings or Mustard procedure
used in D-TGA
not as commonly done today
baffle to redirect systemic and pulmonary venous inflows at the atrial level.
systemic venous flow is directed across the IAS, to the LV, out the PA
pulmonary venous flow is directed across the IAS, to the RV, out the AO (RV is systemic ventricle)
With a senning or mustard repair which ventricle is the systemic ventricle?
right ventricle is the systemic ventricle
usually by 20’s the RV fails and requires a double switch or heart transplant
With a atrial switch procedure there is increase risk for?
mustard/sennings
baffle obstruction/leaks
atrial arrhythmias
subpulmonary stenosis
LVOT obstruction- due to IVS bowing
Right HF
sudden death
Arterial switch procedure involves
Jantene
- detaching the great vessels above the sinuses and re-anastomosis to the opposite vessel
- removing the coronaries from base of AO and reattaching them to the neo-aorta
- the main PA and Pulmonary branches are then pulled anterior to the AO, straddling the AAO (Lecompte maneuver)
What are the risk factors of the arterial switch procedure?
supravalvular PS (most common)
supravalvular AS
coronary artery stenosis/kinking
Damus-Kaye-Stansel is a step of repair often seen with what congenital defects
- DILV
- Single ventricle with subaortic obstruction:
-HLHS
-tricuspid atresia - DORV- Taussing Bing anomaly (subpulmonic VSD and CoA)
Providing an alternative path for blood flow when systemic circulation is obstructed
Damus-Kaye-Stansel is a direct communication between ___ and ___.
DKS consist of ___ closure, and what type of connection?
pulmonary artery and the AAO
VSD closure, and a RV to PA conduit
During the Konno procedure what is done?
Widening of the left ventricle outflow tract (muscular myectomy)
Konno procedure is often used with which other procedure?
Ross procedure
What are indications for the Konno procedure?
Subaortic stenosis with hypoplastic AV
What should you look for post-op Konno procedure?
eval for any ventricle shunting
eval aortic valve
assess residual LVOT obstruction
Ross procedure
use patients own PV to replace the AV, RVOT is directed through RV-PA conduit
Indications for Ross procedure?
Severe AS/AI
What are several types of CoA repair
End-to-end anastomosis
patch augmentation
subclavian flap repair
End-to-end anastomosis repair of the CoA involves?
What type of thoracotomy?
resecting the aortic isthmus and ductal tissue; attaching end-to-end the transverse AO and DAO.
Left posterolateral thoracotomy
advantages and disadvantages of End-to-end CoA repair?
Advantages
* no need for cardiopulmonary bypass
* no prosthetic material
Disadvantages
* only used for small segment repair of DAO
Patch augmentation repair of CoA involves?
What type of thoracotomy
Augments area of coarctation using prosthetic patch material,
Left posterior lateral thoracotomy
advantages and disadvantages of Patch augmentation repair of CoA?
Advantage
* can be used to repair long tubular segmental stenosis
Disadvantage
* uses prosthetic material
* increases risk for aortic aneurysm
What’s the correlation between the LeCompte and Jantene procedure
Jatene procedure refers to the overall “arterial switch operation” used to correct transposition of the great arteries (TGA), while the Lecompte maneuver is a specific technique often employed during a Jatene procedure to position the pulmonary artery in the correct anatomical location; essentially, the Lecompte maneuver is a step within the Jatene procedure, not a separate operation
Where does pericardial effusion tends to collect early on
Tends to collect early on along posterior and inferior walls then will spread to the apex and RA and lastly the RV anterior wall.
Cardiac Tamponade has what effect on inflow patterns during inspiration?
TV inflow pattern will increase with inspiration
decrease with expiration
>60% change
MV inflow patterns will decrease with inspiration
increase with expiration
>30%change
What is an example of systemic to pulmonary shunt?
What type of flow?
BT shunts
Waterston
Potts
Continuous High velocity flow
In the presence of aortic coarctation, the subclavian flap repair consist of
Disadvantage?
Subclavian artery is detached and attached to the distal end of the descending aorta
Sacrifices the distal subclavian artery, reducing blood supply to the left arm.
What are indications for a Norwood procedure?
Single ventricle physiology:
Hypoplastic left heart syndrome
Tricuspid atresia /HRHS
Unbalanced AVSD
When is the first stage of the Norwood procedure performed?
Performed within the first week of life
What is the first stage of the Norwood procedure?
- Neo aorta (Damus connection), native aorta is augmented to the pulmonary valve
- BT shunt is created.
- ASD is created or enlarged.
What does the second stage of the Norwood procedure consist of?
At what age is this performed?
Usually performed at six months of age
1. BT shunt take down
2. Bi-directional Glenn (hemi fontan)
(if a left SVC is present a bilateral bidirectional Glenn shunt may connect LSVC to LPA.
What does the third stage of the Norwood procedure consist of?
At what age is this stage performed?
Usually performed at three years of age
Known as the Fontan procedure
1. IVC blood is routed to the pulmonary arteries.
-Lateral tunnel IVC blood flow is baffled through the RA upward to the pulmonary artery. Sometimes has fenestration into the RA to release Venus pressure (reduce PHTN)
2. Final result is that all systemic Venus return bypasses the heart and goes directly to the lungs.
Fenestration can close on its own or cath intervention with amplatzer device
What is the hybrid procedure?
It’s a staged single-ventricle repair requiring less surgical time, alternative to the three stage Norwood procedure.
What is the hybrid procedure and what does it involve?
Stage I: Allows time to decide on one verse two ventricle repair.
Stenting the PDA
Banding PA branches
ASD is created or enlarged
stage II: Glenn procedure
Stage III: Fontan procedure
When is cardiac transplant deemed necessary?
When no medical or surgical options are effective
A donor heart must match the recipient based off of what factors
Blood type and weight criteria (age)
Following cardiac transplant, how often is an echo exam performed
Usually biweekly for two months, then monthly for the first year.
What is the Golden standard to test heart transplant for rejection?
Endomyocardial biopsy
During a pericardiocenthesis what view is the sonographer asked to obtain for needle guidance?
Apical 4 chamber or subcostal view, sometimes slightly off axis
Normal pericardial fluid will be what color?
What are examples of abnormal pericardial fluid?
Straw colored
Abnormal:
Bloody – associated with trauma or cancer
Infectious – staph
Excessive protein – systemic lupus
Elevated white blood count-fungal infection
Coil occlusion procedure is used to close
PDA
Venus collaterals
Aorta pulmonary collaterals
Coronary artery fistula
Balloon, dilation procedures are not indicated when there is what type of stenosis
Infundibular PS
HCM with sub aortic obstruction
Fibromuscular AS
Supra valvular AS
What are the three current devices used to close ASD’s in Cath Lab?
- Clamshell device aka cardioseal
- Angel wings/guardian angel device. (double disc device.)
- Amplatzer septal occluder: coated woven wire with a small waist, connecting two atrial disc.
Most used currently
Also used for Fontan fenestration closure
VSD amplatzer device criteria
Must be:
muscular VSD
Located 4mm from all valves
- similar to ASD device, however, thicker waist to accommodate for the muscle
Rashkind is what procedure
When is it commonly performed?
Atrial septostomy
DTGA
TAPVR with restrictive ASD
HLHS with restrictive ASD
Tricuspid atresia with restrictive ASD
What are contraindications for a rashkind procedure?
Interrupted IVC
Children older than six weeks
To check for a left SVC via bubble study, the IV must be placed in which arm
Left arm
What are common sedation medication used in pediatrics when having a sedated echo
Chloral hydrate (oral)
Midazolam (oral/nasal)
Fentanyl (intervenous)
Nembutal (oral)
What are pharmacological medicine used in stress test?
Dobutamine
Adenosine
Dipyridamole
What is post-pericardiotomy syndrome
Auto immune response from opening pericardial sac during surgery, results in increase pericardial fluid
