Surgery for CHDs

Question 1

PDA

most common presentation?
what happens to the pulmonary blood flow?

Answer 1

increase incidenxe of respiratory infections
increased pulmonary blood flow

machinery murmur at the left infraclavicular area due to turbulence of blood

Question 2

Indications for PDA close surgery

Answer 2

respiratory distress
recurrent respiratory infection
large, hemodynamically signigicant PDA
failure of 2 courses of indomethacin and ibuprofen

Question 3

Anatomical landmarks for PDA close surgery

Answer 3

PDA is identified by the vagus nerve

Recurrent laryngeal nerve hooks around PDA (paos when cut)

Question 4

Coarctation of aorta distinguishing features

Answer 4

Narrowing of aorta
Diagnosed by 2D echo
Common in males

Question 5

What is the most common associated lesion of CoArc?

Answer 5

Bicuspid aortic valve –> results in aortic stenosis (doesn’t open much during ventricular systole)

Question 6

PE findings of CoArc

Answer 6

BP elevated at the upper ex (above the coarctation)

BP lowered at the lower ex

Femoral and other peripheral pulses are weak or absent

Question 7

Without intervention, CoArc would lead to…

Answer 7

Severe UE hypertension, leads to aneurysm and LV hypertrophy

Question 8

Management of CoArc

Answer 8

IV prostaglandins
Balloon angioplasty
End-to-end anastomosis via left posterolateral thoracoromy

Question 9

ASD

F > M?

Answer 9

F > M

Question 10

ASD irreversible contraindication for surgery, will manifest as a R to L shunt with clubbing

Answer 10

Pulmonary hypertension

Question 11

ASD murmurs that are not true anatomic, but because of high volume entering tricuspid and pulmonic valve

Answer 11

TS and PS

Question 12

ASD PE finding upon auscultation

Answer 12

Wide-split, fixed S2 (lub-d-dub)

Due to delayed pulmonic valve closure, due to increased load

Question 13

ASD X-ray findings

Answer 13

Hypervascularity of pulmonary lung fields

–> increased pulmonary blood flow (also im VSD and PDA)

Question 14

ASD indications for surgery

Answer 14

QP:QS => 1.5:1

2D echo findings - RV volume overload

RA, RV enlargement

+ arrhythmias and heart failure

Question 15

VSD PE finding

Answer 15

Pansystolic murmur

Question 16

VSD types that do not close spontaneously

Answer 16

Outlet and Inlet types

Question 17

VSDs are closed by _______ patch (not pericardium), unlike ASD (patched with pericardium)

Answer 17

PTFE: polytetrafluoroethylene patch

Question 18

Cyanotic CHDs are _____ shunts

Answer 18

R to L shunts

Question 19

Cyanotic Ts

Answer 19

TOF
TGA
True anomalous pulmonary venous return
Tricuspid valve atresia

Question 20

Components of TOF

Answer 20

VSD
Overriding aorta
RV outflow tract obstruction
RV hypertophy

Question 21

TOF clinical characteristics

Answer 21

Mid-systolic ejection murmur at 2nd or 3rd ICS radiating to the axilla

Clubbing
Squatting
Polycythemia
Hemoptysus
Hypercyanotic episodes, Tet spells

Question 22

TOF x-ray findings

Answer 22

Boot-shaped heart - displaced cardiac apex

Dark lung area (low PBF)

Small pulmonary artery

RA enlargrment

Question 23

TOF surgical interventions (can only be cured with surgery)

Answer 23

Palliative:
-shunts (Potts - between left PA to descending aorta; Waterston - between PA and ascending aorta) - augment PBF, especially if px is cyanotic

-Blalock-Taussig-Thonas shunt

Definitive:
-infundibulectomy - removal of hypertrophied muscles (obstruction) from the infundibulum

• enlargement of RV outflow tract
• closing of VSD (can patch)
• artificial monocuspid valve from pericardium to replace dysplastic pulmonic valve
• overriding aorta not corrected, automatically corrected with patching

Question 24

TGA

Answer 24

Aorta from RV, PA from LV –> blood flow is reversed

Common in males

Not compatible with life (if with VSD, PDA, surgery, can live for six months)

Question 25

TGA x-ray findings

Answer 25

Egg on a string

Retrosternal fullness - RA and biventricular enlargement

Question 26

TGA surgical interventions

Answer 26

Balloon atrial septostomy (BAS) - Rashkind

Atrial switch - Mustard and Senning

Arterial repair - Jatene

Valvrd conduit - Rastelli

Question 27

TGA surgical intervention: balloon atrial septostomy - Rashkind

Answer 27

Catheter with O2 monitor inserted from femoral vein, goes to RA, through foramen ovale, to LA

Question 28

TGA surgical intervention: atrial operation - Mustard and Senning - physiological and not anatomical correction

Problem?

Answer 28

Shunt RA blood to LV –> go on the PA

Shunt LA blood to RV –> go on the aorta

RV had no concentric muscles, can’t pump systematically for so long

Question 29

TGA surgical intervention: arterial swith - Jatene

Anatomical and physiological correction

Answer 29

Transpose aorta, coronary arteries, PA, then switch them around

Question 30

TGA surgical intervention: valved conduit - Rastelli procedure

Answer 30

Done in combi with inflow procedure

Use pulmonary or aortic homograft conduit to relieve pulnonary obstruction in double outlet RV with PS

Question 31

Total anomalous pulmonary venous return x-ray

Answer 31

Snowman sign

Question 32

TAPVR surgical intervention

Answer 32

PVeins reconnected to LA

Question 33

Tricuspid valve atresia

PFO?

Commonly includrs VSD and PS

Most common type of single ventricle hypertrophy

Answer 33

Obligatory PFO - RA to LA shunt due to increased pressure

Question 34

TVA surgical treatment

Answer 34

Systemic to pulmonary shunt

Classic Blalock Taussig shunt - Subclavian to PA
Modified - Innominate artery to PA