palliative operation seoul national university hospital department of thoracic & cardiovascular...
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Palliative Operation
Seoul National University Hospital
Department of Thoracic & Cardiovascular Surgery
Aims of Palliative Operations
• Purposes Operations have been designed to alter the hemodynamic physiolog
y, to make the cardiac malformation more tolerable
so as to allow improvement in the patient’s condition, to allow conti
nued growth, and to by time.
• Three principal objectives
Operations to increase pulmonary blood flow
Operations to decrease pulmonary blood flow
Operations to increase pulmonary-systemic mixing
Palliative Procedures in CHD
1 Systemic artery-pulmonary artery shunt Blalock-Taussing in 1945
Potts in 1946
Waterston in 1962
2 Systemic vein-pulmonary artery shunt Glenn in 1958
Fontan & Baudet in 1968
3 Pulmonary artery banding Muller & Dammann in 1952
Palliative Surgery
• Systemic – pulmonary artery shunt Blalock-Taussig shunt Unifocalization and shunt Cavopulmonary shunt (BCPS)
• RVOT reconstruction Valvotomy Patch widening Valved conduit
• Pulmonary artery banding• Atrial septectomy
Systemic–Pulmonary Artery Shunt
Systemic – Pulmonary artery shunt is indicated
due to age, size, anatomy or other conditions
when;
1. Complex anomaly with severe cyanosis,
irritability, hypoxic episode
2. Critically ill neonates or infants due to decreased
pulmonary blood flow
3. Facilitating growth of hypoplastic pulmonary artery
Disadvantages of Classic B-T shunts
1. Longer operative dissection time
2. Phrenic nerve injury
3. Technical difficulties during takedown
4. Possible arm ischemia
Advantages of Sternotomy for Shunt
1) Less demanding for shunt construction with
greater control of vessels without the risk of
lung compression
2) Able to institute cardiopulmonary bypass
3) Complication rate is lower with even flow
distribution
4) Single scar
RMBT Shunt (Midline Approach)
BT Shunt
RMBT Shunt (Midline Approach)1 m. TGA+VSD+PS
BT Shunt
Bidirectional Cavo-pulmonary Connection
BCPC
Bidirectional Cavo-pulmonary Connection
BCPC
Bidirectional Cavo-pulmonary Connection 5m, SV+ PS
BCPC
Thromboembolic Event after Shunt
• Incidence; 3~5%• Etiology 1. Hematologic Inherited abnormality of coagulation factors Protein S, C, factor V Leiden, antithrombin III
2. Mechanical 3. Pulmonary hypertension 4. Infections
• Treatment Warfarin (reducing the Vk dependent proteins) Low-molecular weight heparin Newborns are low in Vk dependent protein( 50% of adult level , reach adult level at 6 months)
Control of congestive heart failure Complex or multiple VSD (with/without CoA) Single ventricle, Tricuspid atresia without PS Protection of pulmonary vascular bed Single ventricle – Fontan operation Preparation of LV for arterial switch operation TGA with IVS / restrictive VSD
Pulmonary Artery Banding
Pulmonary artery banding is indicated to decrease
pulmonary blood flow and prevent pulmonary vascular
obstructive disease when ;
Pulmonary Artery Banding
Aims of banding To decrease the volume of the left to right shunt and thus the work of left ventricle, and minimize pulmonary vascular engorgement and protect the pulmonary vascular disease. ( Sick infants less than 6 months of age, or more, with intractable congestive failure and failure of growth, or with those complex lesions unsuitable for primary repair in infancy )
Pulmonary Artery Banding
Consequence1 Mortality rate
2 Imperfect banding
3 Obliteration of pericardial space
4 Pulmonary artery distortion & maldistribution
5 Thickening of pulmonary valve
6 Subaortic stenosis
Pulmonary Artery Banding• Diagnosis (ILI), Dextrocardia
ECD, IVC interruption ,
1 month old
Pulmonary Artery Banding F/3m, RV-type SV
PA Banding
Pulmonary Artery Banding
Disadvantages 1. Failure to control adequate pulmonary
blood flow
2. Distortion of pulmonary valve and artery
3. Progression of cardiac hypertrophy and
subaortic obstruction
4. Changes of cardiac diastolic & systolic
function
Mixing Procedures
• Operations to increase venous mixing
of pulmonary-systemic venous returns
1. Rashkind septostomy by balloon catheter
2. Park blade atrial septostomy
3. Blalock-Hanlon closed atrial septectomy
4. Palliative atrial switch
Atrial Septectomy
For the increase of effective pulmonary blood flow
and systemic oxygen saturation
Indications of atrial septectomy : TGA Tricuspid atresia Pulmonary atresia with intact vetricular septum MV & LV hypoplasia Decreasing tendency of indication due to early total correction or intervention