balderas - 1030am - repaired congenital heart disease ... · perloff jk, warnes ca, challenges...
TRANSCRIPT
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Repaired Congenital Heart Disease: What did they do & How is it Doing?JULIET J BALDERAS, MD MSPHMarch 22,2018Conrad Manila
Disclosure
• Nothing to Disclose
Repaired Congenital Heart Disease : What Did they Do and How is it DoingConrad Manila March 22‐24, 2018
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General Goals of Congenital Cardiac Surgery • Create physiologically normal circulation
• Decrease hypoxia
‐ increase pulmonary blood flow
‐ create separate pulmonary and systemic circulation
Improve growth to height ration in children
Repaired Congenital Heart Disease : What Did they Do and How is it DoingConrad Manila March 22‐24, 2018
Outcome Objectives of Postoperative Echocardiogram:• What did they do : IMMEDIATE POSTOPERATIVE PERIOD1. Assess CHD Surgeries : reparative, palliative, or revisionary. 2. provide full knowledge of the lesions necessary for post‐operative
care of patients
3. determine potential post‐operative complications being associated with intraoperative management (surgical technique, cardiopulmonary bypass, and perfusion),
Repaired Congenital Heart Disease : What Did they Do and How is it DoingConrad Manila March 22‐24, 2018
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Outcome Objectives of Postoperative Echocradiogram:• How is it Doing : LONGTERM FOLLOW UP AND OUTCOME
1. Related to indicators that affect the longevity of the hemodynamic effects of the repair : immediate 1‐5‐10 year period
2. Related to lesions that may cause:
a. long‐term effects that require re‐operation
b. increase morbidity and mortality‐ Over time
Repaired Congenital Heart Disease : What Did they Do and How is it DoingConrad Manila March 22‐24, 2018
Definitions:
“Residua” vs “Sequelae”
Perloff JK, Warnes CA, Challenges posed by adults with repaired congenital heart disease, Circulation, 2001;103:2637–43.
Repaired Congenital Heart Disease : What Did they Do and How is it DoingConrad Manila March 22‐24, 2018
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Definitions: Residua• ’ Residua refers conditions that are ‘left‐over,’
• that are obligatory to or consequences of the pre‐operative diagnosis and state.
• They are separate from the operative design and are not the result of surgery having fallen short of its objective
Perloff JK, Warnes CA, Challenges posed by adults with repaired congenital heart disease, Circulation, 2001;103:2637–43.
Repaired Congenital Heart Disease : What Did they Do and How is it DoingConrad Manila March 22‐24, 2018
3/14/2018
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Postop Echo Evaluation : ShuntsVentricular Septal Defect
• LEFT HEARTResidual VSD Left ventricular size, ventricular function Aortic valve function Right coronary cusp
prolapse or thickening
• RIGHT HEARTRight ventricular size and function
Right ventricular and pulmonary artery pressuresEvaluate for pulmonary stenosis if prior banding
ECHOCARDIOGRAPIC –GUIDE POSTOP RECOMMENDATION
• RESIDUAL SHUNT REPAIR
SURGERY VS. DEVICE ?
1. Measure size of VSD at LV
and RV side2. Distance of the VSD from the aortic valve at the 5 chamber view
3. Postoperative PA Pressure
Perloff JK, Warnes CA, Challenges posed by adults with repaired congenital heart disease, Circulation, 2001;103:2637–43.
Repaired Congenital Heart Disease : What Did they Do and How is it DoingConrad Manila March 22‐24, 2018
3/14/2018
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Residual VSD shunt
Residual VSD shunt
Size = 0.4‐0.5 cm Gradient = 19mmHg
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Echocardiographic Evaluation of Repaired AVSeptal Defect
CHECKLIST • 1. Residual VSD / ASD
• 2.Residual Mitral Regurgitation
• 3. Residual Left Ventricular Outflow Tract Obstruction
• 4 . Postoperative
Pulmonary Arterial Hypertension
S/P AVSD REPAIR
MR jet = 67 mmHg
TR jet = 75 mmHg
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Coarctation of the Aorta : Check Long-term ComplicationsCHECKLIST• 1. Arterial hypertension May occur even with optimal repair
• 2.Blood pressure in left arm may be inaccurate
• 3. Re‐coarctation or residual coarctation Aneurysms
Red Flag: Residual
Doppler gradient : > 25 mmHg
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Post COA repair with residual
RESIDUAL COA = 63 mmHg
Echocardiographic Evaluation of Repaired Coarctation of the Aorta
CHECKLIST • 1. Aortic size
• Proximal and distal velocity through repair
• 2. Abdominal Doppler
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Longterm Complications: Tetralogy of Fallot• Pulmonary insufficiency and RV dysfunction
• Transannular patch associated with significant PI• Arrhythmias Supraventricular and ventricular
• Sudden death • Exercise intolerance Decreased compared with age matched controls
Echocardiographic Evaluation of TOF Total Correction
CHECKLIST • 1.Right heart size and function
• 2. Pulmonary regurgitation
• 3. Pulmonary stenosis
• 4. Left ventricular size and function
• 5. Aortic size and aortic valve function
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s/p TOF repair with PR
Residual Pulmonic Stenosis
47 mmHg
Pulmonic Regurgitation 32 mmHg
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Postoperative Echocardiographic Assessment : Arterial Switch Operation:
CHECK LIST
• 1. RV/LV size and function
• 2. AV valve function
• 3. Aortic dimension and neo‐aortic valve function
• 4. Subpulmonic stenosis
• 5. Aortic size
DTGA s/p ASO
Neoaortic root regurgitation
Peak gradient = 44mmHg
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Definitions: Sequelae• ’ consist of incurred conditions that arise as a result of the operation
• considered necessary consequences of the operation.
• They are specifically ‘intrinsic to the operative design.
• Examples include ventricular tachyarrhythmias after ventriculotomyand pulmonary regurgitation after tetralogy repair.
Perloff JK, Warnes CA, Challenges posed by adults with repaired congenital heart disease, Circulation, 2001;103:2637–43.
Repaired Congenital Heart Disease : What Did they Do and How is it DoingConrad Manila March 22‐24, 2018
PERSISTENT Postoperative Pulmonary Hypertension after Surgical Closure of Shunt Lesions
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Pulmonary hypertension / RV FUNCTION
Echo parameter Patient
RV Ejection Fraction byFAC 30%
Myocardial Performance Index (TDI)MPI = (IVCT+IVRT)/ET
0.7
S’ wave velocity (TDI) 6 cm/sec
Pulmonary hypertension
Echo parameter
Left Ventricular Eccentricity Index
End Sytole = 2End diastole = 2(Normal EI = 1)
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Echo parameter Patient
Mean Pulmonary artery pressure
mPAP = 79 – 0.45 (RVOT AT) 81 mmHg
Mean PAP by Tricuspid regurgitation jet
125mmHg
Mean PAP = 4(PR VBD)2 100 mmHg
Pulmonic Regurgitation in TOF and RV Failure leading to Pulmonary Valve replacement