The document discusses cyanotic congenital heart disease, specifically Fallot's Tetralogy. It describes the pathophysiology of Fallot's Tetralogy, including a ventricular septal defect, pulmonary stenosis, and partial lung perfusion causing cyanosis. It outlines complications like syncope, polycythemia, and cerebral infarction. Symptoms include cyanosis, clubbing of fingers and toes, and exertional dyspnea. Investigations and treatments are also summarized, including palliative anastomotic procedures and total surgical correction between ages 5-10 years.

2. Classification:
 Acyanotic congenital heart disease.
 Cyanotic congenital heart disease.
Patients become cyanosed very soon after birth

3. CYANOTIC CONGENTIAL HEART DISEASES
A. Fallot’s Tetralogy:

4. 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.

5. COMPLICATIONS
•Lose of consciousness due to cerebral anorexia
•Polycythemia
•About 1/3 of patients are cyanotic at birth, these patients often
do not survive infancy unless operation is performed quickly.
•Threat to life in the 1st year is cerebral infarction
•Brain abscess

6. 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.

7. 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

8. Fallot’s Tetralogy
Anastomotic palliative treatment:
1.Blalock’s anastomosis: performed on child of a few weeks to 5 years
Anastomosis of pulmonary artery to the left subclavian artery.
Incision: A left postero-lateral thoracotomy
through the 4th intercostal space.
2.Waterston’s anastomosis
Anastomosis of ascending aorta and
right pulmonary artery.
Incision: A right antero-lateral
thoracotomy through the 4th intercostal
space.
3.Pott’s Anastomosis
Anastomosis of ascending aorta to left pulmonary artery.

9. Fallot’s Tetralogy
Total 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…

10. Fallot’s Tetralogy
Ventriculotomy 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

11. •After correction there may be alveolar edema.
•It may be necessary to prolong artificial ventilation with the
use of PEEP.
•And to wean the patient off the ventilator with the use of CPAP.
•Breathing exercise with emphasis on inspiration are
particularly important.
•Fine shaking and percussion to be helpful in the resolution of
the peripheral lung involvement.
•Discharge is btw 2 & 3 weeks, total correction is preffered
before school age.

12. •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 series
are in parallel.

13. •The pulmonary and systemic circulations are separated.
•Venous blood circulate round the body while oxygenated blood
circulate round the lungs.
•For the child be survive there must be a communication btw
two circulation.
•Possible communications are persistent ductus
arteriosus, arterial septal defect or ventricular septal defect.

14. SYMPTOMS:
•Deeply Cyanotic at birth(80%)
•Syncope
•Dyspneoa on exertion
•Cardiac failure
•Clubbing & Polycythemia

15. TRANSPOSITION OF GREAT VESSELS
Surgical 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.

16. 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

17. •The pulmonary venous drainage has become disconnected
from 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 patent
foramen ovale.

18. •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 the
pulmonary artery increases as a result of the increased flow.
•Increased pulmonary HT leads to equalization of pressure
either side of shunt, but, at some point, the right-sided pressure
will exceed and desaturated blood enters the Lt side of the
circulation

19. Symptoms:
oCyanosis
oDyspneoa
•It is irreversible diseases
•Closer of the shunt is contraindicated if pulmonary HT is
irreversible bcoz the Rt-to-Lt shunt now serves to decompress
the pulmonary circulation

20. Physiotherapy Treatment :
Pre-operative Treatment :
•Infants with cardiac problem have pulmonary hypertension
associated with excessive secretion leading to repeated chest
infection.
•So chest physiotherapy important that the lung field are clear as
possible prior to the surgery.
Percussion
Shaking and vibrations
Postural drainage

21. Post-operative Treatment :
•Carefully watch the patient’s vital signs at all times.
•As soon as the child is stable, usually use the side lying
position, with care not to disrupt line, wires or infusions.
•In some unit treatment will be on the day of operation, in
others, day after.
•Depends on the type of operation the patient may or may
not be ventilated.
•Patients should be assessed and physiotherapy given as
necessary.

22. •Percussion and vibrations should be avoided if post operative
bleeding is persistent.
•Manual hyperinflation may enhance secretion clearance and
negligible effect on oxygen saturation (Hussey et al,1996).
•Patient’s have small amount of secretions easily removed by
suction alone.
•Early mobilization is important to stimulate deep breathing
and coughing.
•Nasopharyngeal suction may be used in infants and children.

23. 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.

24. •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 the
abdominal viscera

25. 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 edition
6.)Tidy’s Physiotherapy, Twelfth edition

26. THANK YOU