Fallot’s Tetralogy:• Ventriculoseptal defect results in equal pressure within both ventricles.• As a result of the pulmonary stenosis, more blood is discharge into the aorta and cyanosis results.• Lungs are only partially perfused and total oxygen is poor.• Anomaly results in right to left interventricular shunt due to right outflow tract obstruction and high right ventricular pressure.
COMPLICATIONS•Lose of consciousness due to cerebral anorexia•Polycythemia•About 1/3 of patients are cyanotic at birth, these patients oftendo not survive infancy unless operation is performed quickly.•Threat to life in the 1st year is cerebral infarction•Brain abscess
SYMPTOMS: •Asymptomatic at birth. soon after, infants become cyanosis. •Systemic cyanosis •Undersize child •Clubbing of finger and toes •Exertional dyspneoa and tiredness. •After walking a short distance, body spontaneous desire to squat: increase systemic vascular resistance & blood is diverted into the pulmonary circulation with increase oxygenation.
INVESTIGATION •Heart of normal size •A systolic murmur present at 3rd & 4th intercostal space. •X-ray: Boot-shaped with poorly developed lung vasculature. •ECG •Cardiac catheterization •Selective angiocardiography
Fallot’s TetralogyAnastomotic palliative treatment:1.Blalock’s anastomosis: performed on child of a few weeks to 5 yearsAnastomosis of pulmonary artery to the left subclavian artery. Incision: A left postero-lateral thoracotomy through the 4th intercostal space.2.Waterston’s anastomosisAnastomosis of ascending aorta andright pulmonary artery. Incision: A right antero-lateral thoracotomy through the 4th intercostal space.3.Pott’s AnastomosisAnastomosis of ascending aorta to left pulmonary artery.
Fallot’s TetralogyTotal correction:Technique: performed btw 5 and 10 years of child age Operation carried out through median sternotomy with help of extracorporeal circulation High vertical ventriculotomy perform which stop near the pulmonary annulus through this incision ventricular septal defect closed with dacron patch Pulmonary vulvular and infundibular obstruction is also widened with patch graft of dacron Continue…
Fallot’s TetralogyVentriculotomy closed with dacron patch, extracorporeal circulation is stopped Measured intracardiac pressure to confirm the right ventricular systolic pressure reduced to less than 60 to 70% of that of left ventricle. This operation risk is about 10% for small children, only 2 to 5% in older children
•After correction there may be alveolar edema.•It may be necessary to prolong artificial ventilation with theuse of PEEP.•And to wean the patient off the ventilator with the use of CPAP.•Breathing exercise with emphasis on inspiration areparticularly important.•Fine shaking and percussion to be helpful in the resolution ofthe peripheral lung involvement.•Discharge is btw 2 & 3 weeks, total correction is prefferedbefore school age.
•The Condition was first described by Morgagny.•Aorta arises from Rt ventricle, pulmonary artery arises from Lt ventricle.•The two circulations, pulmonary and systolic,instead of being in seriesare in parallel.
•The pulmonary and systemic circulations are separated.•Venous blood circulate round the body while oxygenated bloodcirculate round the lungs.•For the child be survive there must be a communication btwtwo circulation.•Possible communications are persistent ductusarteriosus, arterial septal defect or ventricular septal defect.
SYMPTOMS: •Deeply Cyanotic at birth(80%) •Syncope •Dyspneoa on exertion •Cardiac failure •Clubbing & Polycythemia
TRANSPOSITION OF GREAT VESSELSSurgical procedure; palliative treatment:1.Procedure is balloon septostomy ruptured(Rashkind and Miller,1966) to create an atrial shunt.2. Atrial septal is excised (Blalock and Hanlon,1950)The Rt atrium and pulmonary vein are parallely incised.A portion of the atrial septum is excised and two incisions are now anastomosed.
Total anatomical correction:Disconnecting the pulmonary artery from left ventricle and aorta from right ventricle Coronary artery must be implanted onto the pulmonary artery, acting as major vessel from Lt ventricle
•The pulmonary venous drainage has become disconnectedfrom the left atrium•And drains into the systemic venous circulation at some point oInferior vena cava, oSuperior vena cava, oCoronary sinus, oRight atrium•There is mixing of the pulmonary circulation though a patentforamen ovale.
•Occurs in the reversal of the left-to-right shunt.•Some of conditions are: oAtrial and ventricular septal defect, oPatent ductus arteriosus.•But the Rt ventricle hypertrophies and the pressure in thepulmonary artery increases as a result of the increased flow.•Increased pulmonary HT leads to equalization of pressureeither side of shunt, but, at some point, the right-sided pressurewill exceed and desaturated blood enters the Lt side of thecirculation
Symptoms: oCyanosis oDyspneoa•It is irreversible diseases•Closer of the shunt is contraindicated if pulmonary HT isirreversible bcoz the Rt-to-Lt shunt now serves to decompressthe pulmonary circulation
Physiotherapy Treatment :Pre-operative Treatment :•Infants with cardiac problem have pulmonary hypertensionassociated with excessive secretion leading to repeated chestinfection.•So chest physiotherapy important that the lung field are clear aspossible prior to the surgery. Percussion Shaking and vibrations Postural drainage
Post-operative Treatment :•Carefully watch the patient’s vital signs at all times.•As soon as the child is stable, usually use the side lyingposition, with care not to disrupt line, wires or infusions.•In some unit treatment will be on the day of operation, inothers, day after.•Depends on the type of operation the patient may or maynot be ventilated.•Patients should be assessed and physiotherapy given asnecessary.
•Percussion and vibrations should be avoided if post operativebleeding is persistent.•Manual hyperinflation may enhance secretion clearance andnegligible effect on oxygen saturation (Hussey et al,1996).•Patient’s have small amount of secretions easily removed bysuction alone.•Early mobilization is important to stimulate deep breathingand coughing.•Nasopharyngeal suction may be used in infants and children.
Specific consideration: •Pulmonary HT crises. Elevation of pulmonary artery pressure which restricts flow through the lungs. Air way suction and chest physiotherapy is indicated, inspired oxygen should be increased & treatment time kept to a minimum. •Delayed sternal closure Occasionally post operative closer of sternum is impended by pulmonary, myocardial or chest wall edema. If child is stable and if the sternum edges feels, the child can turned into a side lying position Manual hyperinflation is well tolerated and gentle posterior and posterolateral vibrations can be applied.
•Phrenic nerve damage oItis a well-documented complication of pediatric cardiac surgery(Main,1995). oInability to wean from mechanical ventilation. oParadoxical movement is present.Patient is positioned head up to relive the pressure from theabdominal viscera
References :1.) Textbook of surgery by, S.Das , 5th Edition.2.) Bailey & Love’s Short practice of surgery , 22nd Edition.3.) Davidson’s Principles & practice of medicine , 20th Edition.4.) Cash’s Textbook of Chest , Heart and Vascular Disorders for Physiotherapists , 4th Edition.5.) physiotherapy for respiratory and cardiac problems ( pryor and prasad) third edition6.)Tidy’s Physiotherapy, Twelfth edition