Surgical indications of ASD, VSD.ppt


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Surgical indications of ASD, VSD.ppt

  1. 1. Surgical Indication Atrial Septal Defect
  2. 2. Anatomical Indications <ul><li>Uncomplicated ASD </li></ul><ul><li>PAPVC (partial anomalous pulmonary venous connection, PAPVR) with evidence of RV volume overload </li></ul>
  3. 3. Hemodynamic Indications <ul><li>Pulmonary-systemic blood flow ratio ( Qp/Qs ) ≧ 2 </li></ul><ul><li>uncomplicated anomaly Qp/Qs≧ 1.5 </li></ul><ul><ul><li>Exception: Scimitar syndrome (=PAPVR) with severe hypoplasia of the right lung and a Qp/Qs<2 (However, surgery may be needed because of complications of bronchopulmonary sequestration) </li></ul></ul>
  4. 4. PAPVC <ul><li>Isolated PAPVC of a part of one lung without an ASD is not an indication when the Qp/Qs<1.8 </li></ul><ul><li>Isolated PAPVC of a whole lung is an indication (should the normal lung be importantly compromised potentially fatal anoxia occurs) </li></ul>
  5. 5. Age <ul><li>Age < 5 y/o (1~2y/o can be considered for deleterious effects of long- termed RV volume overload), but diagnosis was often made later in life </li></ul><ul><li>Age is not an contraindication (very young or very old) </li></ul>
  6. 6. Pulmonary vascular resistance <ul><li>Pulmonary vascular resistance= 8~12 U ·m 2 at rest and cannot decrease to less than 7 under pulmonary vasodilator were surgical contraindication (Qp/Qs<1.5 with elevated pulmonary artery pressure is often, sometimes present with Qp/Qs=2) </li></ul>
  7. 7. Associated TR, MR <ul><li>Associated TR and/or MR (present particularly in older patients) is not a contraindication to operation </li></ul><ul><ul><li>Grading of MR angiography is difficult (ASD present and major runoff from left to right antrium) and regurgitation became important when ASD closed </li></ul></ul><ul><ul><li>Moderate MR is usually an indication for MVR </li></ul></ul>
  8. 8. Summary <ul><li>Pulmonary-systemic blood flow ratio ( Qp/Qs ) ≧ 2 </li></ul><ul><li>Pulmonary vascular resistance= 8~12 U ·m 2 at rest and cannot decrease to less than 7 under pulmonary vasodilator were surgical contraindication </li></ul>
  9. 9. Ventricular Septal Defect
  10. 10. <ul><li>A schematic presentation of the three main anatomic components of the interventricular septum as seen from the morphologic right ventricle (A) and the morphologic left ventricle (B). Component 1: septum of the atrioventricular canal; Component 2: septum of the muscular septum; and Component 3: parietal band or distal conal septum. </li></ul>
  11. 11. <ul><li>Planes of Doppler interrogation for different ventricular septal defects as seen in parasternal short axis. </li></ul>
  12. 12. Surgical Indications: Symptom <ul><li>Approximately 30% of infants with severe symptoms form VSDs requires operation within the first year of life because of intractable congestive heart failure or, more commonly, failure to thrive </li></ul><ul><ul><li>Symptomatic: Qp/Qs>1.5, pulmonary artery systolic pressure > 50mmHg, increased LV and LA size, or LV dysfunction </li></ul></ul>
  13. 13. <ul><li>The majority of membranous and muscular VSDs tend to close spontaneously . </li></ul><ul><ul><li>Surgical closure early in life is indicated only if the infant has failed aggressive medical management with digitalis and diuretics </li></ul></ul>
  14. 14. Asymptomatic infant with persistent VSD <ul><li>Cardiac catheterization should be performed at the end of the first year of life. If pulmonary artery pressure > ½ systemic pressure , closure should be performed. </li></ul>
  15. 15. Hemodynamic Indication <ul><li>Qp/Qs≧1.5 </li></ul><ul><li>Pulmonary artery systolic pressure > 50mmHg </li></ul>
  16. 16. Pulmonary Vascular Resistance <ul><li>If pulmonary arteriolar resistance is less than 7 Wood units , closure can be safely undertaken </li></ul><ul><li><1y/o , with VSD, pulmonary-to-systemic vascular resistance >0.7 are still considered surgical candidates </li></ul><ul><ul><li>because the likehood that elevated pulmonary vascular resistance reflects irreversible pulmonary vascular change within the first year of life is extremely small. </li></ul></ul>
  17. 17. Aortic Incompetence <ul><li>VSD with first showed the development of the murmur of aortic incompetence (AI), repair of VSD should be promptly accomplished while the AI still mild </li></ul><ul><li>Cusp prolapse was showed in association with any juxtaaortic VSD , early repair is also indicated </li></ul><ul><li>Juxtaarterial VSDs and right ventricular outflow juxtaaortic VSDs of significant size, even without cusp prolapse should be closed before 5y/o , to prevent cusp prolapse </li></ul>
  18. 18. Aortic Incompetence <ul><li>When moderate or severe AI and cusp prolapse were noted, operation should be undertaken promptly. It should be done before 10y/o </li></ul><ul><ul><li>Reconstruction of the valve is usually possible when OP is done during the first decade of life </li></ul></ul><ul><ul><li>UAB: the average age of the patients requiring replacement was 19.5 years, compared with 12.1 years for the remainder of the group </li></ul></ul>
  19. 19. Aortic Incompetence <ul><li>When no cusp prolpase and severe AI with minimal enlargement of the sinuses is present, a bicuspid valve is probably present, and valve replacement may be required. (It means AR was not induced by VSD ) VSD repair should be postponed until significant symptoms develop or LV enlargement itself indicates the need of for operation </li></ul><ul><li>When the operation is delayed until adult life, aortic valve replacement is usually required. </li></ul>
  20. 20. Summary (1) <ul><li>Surgical indications </li></ul><ul><ul><li>Qp/Qs≧1.5 </li></ul></ul><ul><ul><li>Pulmonary artery systolic pressure > 50mmHg </li></ul></ul><ul><ul><li>pulmonary arteriolar resistance < 7 Wood units </li></ul></ul><ul><ul><li>VSD related AI (RCC prolapse, NCC prolapse) </li></ul></ul>
  21. 21. Summary (2) <ul><li>Membranous and muscular type VSD may close spontaneously </li></ul>
  22. 22. References <ul><li>Kirlin Cardiac Surgery </li></ul><ul><li>Zipes: Braunwald’s Heart Diseae: A Textbook of Cardiovascular Medicine </li></ul><ul><li>Park: Pediatric Cardiology for Practitioners </li></ul><ul><li>Cardiac surgery of the neonate and infant </li></ul>