1. Congenitally corrected transposition of the great arteries (cc-TGA) involves atrioventricular and ventriculoarterial discordance.
2. Patients often present with ventricular septal defects, heart block, or ventricular dysfunction. The risk of complete heart block increases by 2% each year.
3. Surgical options include repair of associated defects while maintaining discordance, or an anatomic repair to place the morphological left ventricle as the systemic ventricle. The approach depends on the severity of lesions and individual patient factors.
Congenitally corrected transposition of the great arteries (CC TGA) is a rare congenital heart defect where the ventricles are connected abnormally at the atrioventricular and ventriculoarterial junctions, physiologically correcting the discordance. It typically presents with other defects like ventricular septal defects and pulmonary stenosis. Surgical repair focuses on closing ventricular septal defects and treating pulmonary stenosis or tricuspid valve issues, but carries risks of heart block and low survival rates long term.
This document discusses the anatomy, embryology, and management of L-TGA (transposition of the great arteries). Some key points:
- In L-TGA, the ventricles are inverted such that the morphologic right ventricle is on the left and pumps blood to the lungs, while the morphologic left ventricle is on the right and pumps blood to the body.
- Embryologically, abnormal leftward looping of the heart tube during development results in the inverted ventricles. The conduction system and coronary arteries also have abnormal anatomy.
- Clinical features may include congenital heart block, progressive tricuspid regurgitation, pulmonary stenosis, and heart failure. Diagn
Congenitally corrected transposition of great arteriesDheeraj Sharma
This document provides an overview of congenitally corrected transposition of the great arteries (CCTGA). Key points include:
- CCTGA is a rare congenital heart defect where the ventricles are transposed but the atria are connected to the physically opposite ventricles, resulting in circulatory pathways in series.
- Patients may be asymptomatic for years but eventually develop right ventricular failure or left ventricular outflow tract obstruction. Diagnosis is made through physical exam, chest x-ray, and electrocardiogram showing right ventricular hypertrophy.
- Associated anomalies include ventricular septal defects, pulmonary stenosis, Ebstein's anomaly of the tricuspid valve, and heart block. Surgical
This document discusses the history, diagnosis, and treatment of transposition of the great arteries (TGA). It notes that TGA is a congenital heart defect where the aorta arises from the right ventricle and the pulmonary artery from the left ventricle. The document outlines the key developments in the surgical treatment of TGA, from early septostomies and shunts to the arterial switch procedure. It also describes the clinical presentation and management of different variations of TGA.
1) Transthoracic and transesophageal echocardiography are important modalities for assessing atrial septal defects (ASDs). TTE can identify RV volume overload and septal flattening, while TEE precisely measures defect size and evaluates rim morphology.
2) The four main types of ASDs - ostium secundum, ostium primum, sinus venosus, and coronary sinus defects - have distinguishing echo features. Doppler can demonstrate shunt direction and magnitude.
3) Echocardiography guides percutaneous ASD closure by assessing defect and rim anatomy, device sizing, and post-procedure result. Understanding echo features is key to ensuring procedure success.
D-Transposition, also known as dextro-Transposition of the great arteries (d-TGA), is a congenital heart defect where the ventricles are connected to the wrong great arteries. Specifically, the aorta arises from the right ventricle while the pulmonary artery arises from the left ventricle. This causes two parallel circulations instead of the normal series circulation. The basic embryological defect is abnormal development of the conus, which prevents normal septal formation between the great arteries. Untreated d-TGA is fatal in infancy due to lack of oxygenated blood to the body. Clinical presentation depends on the degree of mixing between the circulations.
The document discusses atrioventricular septal defects (AVSDs), which are characterized by the complete absence of the atrioventricular septum. It describes the anatomy, classification, epidemiology, presentation, investigations, and management of AVSDs. Key points include that AVSDs can be partial or complete, account for 4-5% of congenital heart disease, and require surgical repair in early infancy to prevent congestive heart failure and pulmonary hypertension. Left ventricular outflow tract obstruction is a potential postoperative complication.
This document discusses development of percutaneous mitral valve repair techniques and clinical trials. It provides background on chronic mitral regurgitation (MR) and the limitations of medical and surgical treatment. Percutaneous mitral valve repair offers benefits over surgery like reduced morbidity and shorter recovery. The document describes the four main percutaneous repair methods and focuses on the MitraClip edge-to-edge leaflet repair system, including patient selection criteria, procedure steps, and clinical trial results demonstrating safety and effectiveness for treating MR.
Congenitally corrected transposition of the great arteries (CC TGA) is a rare congenital heart defect where the ventricles are connected abnormally at the atrioventricular and ventriculoarterial junctions, physiologically correcting the discordance. It typically presents with other defects like ventricular septal defects and pulmonary stenosis. Surgical repair focuses on closing ventricular septal defects and treating pulmonary stenosis or tricuspid valve issues, but carries risks of heart block and low survival rates long term.
This document discusses the anatomy, embryology, and management of L-TGA (transposition of the great arteries). Some key points:
- In L-TGA, the ventricles are inverted such that the morphologic right ventricle is on the left and pumps blood to the lungs, while the morphologic left ventricle is on the right and pumps blood to the body.
- Embryologically, abnormal leftward looping of the heart tube during development results in the inverted ventricles. The conduction system and coronary arteries also have abnormal anatomy.
- Clinical features may include congenital heart block, progressive tricuspid regurgitation, pulmonary stenosis, and heart failure. Diagn
Congenitally corrected transposition of great arteriesDheeraj Sharma
This document provides an overview of congenitally corrected transposition of the great arteries (CCTGA). Key points include:
- CCTGA is a rare congenital heart defect where the ventricles are transposed but the atria are connected to the physically opposite ventricles, resulting in circulatory pathways in series.
- Patients may be asymptomatic for years but eventually develop right ventricular failure or left ventricular outflow tract obstruction. Diagnosis is made through physical exam, chest x-ray, and electrocardiogram showing right ventricular hypertrophy.
- Associated anomalies include ventricular septal defects, pulmonary stenosis, Ebstein's anomaly of the tricuspid valve, and heart block. Surgical
This document discusses the history, diagnosis, and treatment of transposition of the great arteries (TGA). It notes that TGA is a congenital heart defect where the aorta arises from the right ventricle and the pulmonary artery from the left ventricle. The document outlines the key developments in the surgical treatment of TGA, from early septostomies and shunts to the arterial switch procedure. It also describes the clinical presentation and management of different variations of TGA.
1) Transthoracic and transesophageal echocardiography are important modalities for assessing atrial septal defects (ASDs). TTE can identify RV volume overload and septal flattening, while TEE precisely measures defect size and evaluates rim morphology.
2) The four main types of ASDs - ostium secundum, ostium primum, sinus venosus, and coronary sinus defects - have distinguishing echo features. Doppler can demonstrate shunt direction and magnitude.
3) Echocardiography guides percutaneous ASD closure by assessing defect and rim anatomy, device sizing, and post-procedure result. Understanding echo features is key to ensuring procedure success.
D-Transposition, also known as dextro-Transposition of the great arteries (d-TGA), is a congenital heart defect where the ventricles are connected to the wrong great arteries. Specifically, the aorta arises from the right ventricle while the pulmonary artery arises from the left ventricle. This causes two parallel circulations instead of the normal series circulation. The basic embryological defect is abnormal development of the conus, which prevents normal septal formation between the great arteries. Untreated d-TGA is fatal in infancy due to lack of oxygenated blood to the body. Clinical presentation depends on the degree of mixing between the circulations.
The document discusses atrioventricular septal defects (AVSDs), which are characterized by the complete absence of the atrioventricular septum. It describes the anatomy, classification, epidemiology, presentation, investigations, and management of AVSDs. Key points include that AVSDs can be partial or complete, account for 4-5% of congenital heart disease, and require surgical repair in early infancy to prevent congestive heart failure and pulmonary hypertension. Left ventricular outflow tract obstruction is a potential postoperative complication.
This document discusses development of percutaneous mitral valve repair techniques and clinical trials. It provides background on chronic mitral regurgitation (MR) and the limitations of medical and surgical treatment. Percutaneous mitral valve repair offers benefits over surgery like reduced morbidity and shorter recovery. The document describes the four main percutaneous repair methods and focuses on the MitraClip edge-to-edge leaflet repair system, including patient selection criteria, procedure steps, and clinical trial results demonstrating safety and effectiveness for treating MR.
This document discusses the embryology, anatomy, clinical presentation, evaluation, and surgical treatment of pulmonary atresia with ventricular septal defect (PA-VSD). Some key points:
- PA-VSD is characterized by atresia of the pulmonary artery and a ventricular septal defect, with pulmonary blood flow derived from collateral arteries.
- Pulmonary blood supply can be unifocal from sources like a patent ductus arteriosus or multifocal from multiple aortopulmonary collateral arteries.
- Surgical repair aims to connect as many lung segments as possible to right ventricular outflow during infancy to avoid pulmonary vascular changes, with the ultimate goal of complete repair closing all defects and incorporating
This document discusses the anatomy and electrocardiogram (ECG) patterns of different types of single ventricle heart defects. It describes 4 types - A, B, C, and D - based on the morphology and dominance of the left or right ventricle. The location of the conduction system and ECG patterns depend on factors like whether the outlet chamber is inverted or not, and the trabecular morphology. Non-inverted outlets with left ventricular dominance typically show left axis deviation on ECG, while inverted outlets with right dominance show right axis deviation. The document provides detailed descriptions of the anatomical variations and their corresponding ECG characteristics.
This document discusses atrioventricular septal defects (AVSDs), including their embryogenesis, classification, clinical features, imaging, and management. It describes the spectrum of AVSDs from partial to complete. Partial AVSDs involve a primum atrial septal defect with a cleft in the mitral valve. Complete AVSDs have a large ventricular septal defect with a common atrioventricular valve. Imaging like echocardiography is important for evaluating the anatomy and determining appropriate treatment, which ranges from observation to surgical repair.
This document discusses the Norwood procedure for treating hypoplastic left heart syndrome (HLHS). It begins with an overview of the seminar topics, including the physiology of HLHS, palliative measures, and staged surgical options. It then delves into detailed anatomy and morphology, defining HLHS and discussing major subtypes. The remainder covers clinical presentation, diagnostic testing methods like echocardiography and cardiac catheterization, and historical milestones in HLHS management.
Both the remodeling and reimplantation techniques aim to preserve the native aortic valve in patients with aortic root aneurysms. The remodeling technique involves excising the diseased sinuses and reattaching the valve within a graft, reconstructing the sinuses. The reimplantation technique reimplants the valve within a graft anchored at the aortoventricular junction. Studies have found slightly better long-term outcomes with reimplantation, especially in conditions like Marfan syndrome or dissection, though both techniques have good results. Neither technique fully restores the normal biomechanics and stress patterns of the native aortic root.
This document discusses atrioventricular canal defects (AVSDs), including their embryogenesis and pathophysiology. It describes the anatomy and classification of partial and complete AVSDs. Partial AVSDs involve a primum atrial septal defect with two distinct but contiguous AV valves, while complete AVSDs have a single common AV valve. The embryogenesis of AVSDs involves faulty development of the endocardial cushions. The document provides detailed descriptions and images of the anatomy and features of partial and complete AVSDs. It discusses the clinical aspects of AVSDs including prevalence, association with Down syndrome, surgical repair outcomes, and lifelong surveillance needs.
This document discusses atrioventricular septal defects (AVSDs). It begins with epidemiology, noting a prevalence of 4-5% of congenital heart defects. It then covers embryology, anatomy, pathology, classification, clinical features, diagnosis and management. Key points include abnormal development of endocardial cushions leading to absence of AV septum and common atrioventricular valves. Clinical features include congestive heart failure in infancy. Diagnosis is made via echocardiogram showing absent AV septum. Surgical repair aims to close defects and preserve left AV valve competence.
TGA is a complex congenital heart disease.Understanding the anatomy,physiology,surgery and anaesthetic management is very important for patient's better outcome.This ppt explains all these points in detail.
1) Atrial septal defects are one of the most common types of pre-tricuspid shunts and can often remain asymptomatic until later in life when they may lead to heart failure, pulmonary hypertension, or arrhythmias if left unrepaired.
2) The natural history and prognosis of atrial septal defects depends on factors like the size of the defect and age at diagnosis, with smaller defects having higher rates of spontaneous closure and repair at a younger age leading to better outcomes.
3) Device or surgical closure of atrial septal defects can successfully close the defect and improve symptoms, but the best outcomes are seen in those with less elevated pulmonary pressures and cardiac chamber enlargement prior to repair
SCAD is a rare, sometimes fatal, traumatic condition with approximately eighty percent of cases affecting women. The coronary artery can suddenly develop a tear, causing blood to flow between the layers which forces them apart, potentially causing a blockage of blood flow through the artery and a resulting heart attack. The condition may be related to female hormone levels, as it is often seen in post-partum women, or in women during or very near menstruation, but not always. It is not uncommon for SCAD to occur in people in good physical shape and with no known prior history of heart related illness. It is also not uncommon for SCAD to occur in people in their 20's, 30's, and 40's, as well as older.
- L-TGA, also known as corrected transposition of the great arteries, is a rare congenital heart defect where the ventricles are transposed and the atrioventricular valves are discordant.
- The embryological cause is abnormal leftward looping of the heart during development, resulting in the morphologic right ventricle being on the left side and pumping blood to the lungs, while the morphologic left ventricle is on the right side and pumps blood to the body.
- Associated abnormalities are common, including ventricular septal defects, pulmonary stenosis, tricuspid valve anomalies, and conduction system abnormalities. Long term, the right ventricle is poorly suited to function as the systemic
This document discusses peripheral pulmonary artery stenosis, including its description, associated conditions, classification, clinical features, diagnosis using imaging modalities like echocardiography and angiography, and treatment options like balloon angioplasty. Peripheral pulmonary artery stenosis can involve the main pulmonary artery or its branches and is present in 2-3% of congenital heart disease cases. Diagnosis relies on cardiac catheterization and angiography to determine severity and anatomy. Balloon angioplasty is an option for treating moderate or severe stenosis when surgery is difficult.
1) Cavopulmonary connections like the Glenn shunt divert systemic venous return directly to the pulmonary circulation, improving oxygen saturation for patients with single ventricle physiology.
2) The Glenn shunt involves anastomosis of the superior vena cava to the right pulmonary artery, reducing the volume load on the single ventricle.
3) Immediate postoperative issues include managing ventilation, elevated cavopulmonary pressures, hypertension/bradycardia, low cardiac output, and cyanosis which may result from pulmonary or systemic venous desaturation or decreased pulmonary blood flow.
An atrioventricular canal defect, also known as an endocardial cushion defect, is characterized by a complete absence of the atrioventricular septum. It results from abnormal differentiation and remodeling of endocardial cushion mesenchyme that fails to form the septal tissue. It presents with a common atrioventricular ring, a five leaflet valve guarding the common AV orifice, and an unwedged left ventricular outflow tract. Surgical repair is usually done between 2 to 4 months of age to close the septal defects and reconstruct the valves. Techniques include single patch, double patch, and modified single patch closure.
Tetralogy of Fallot (TOF) is a congenital heart defect characterized by four anatomical abnormalities - ventricular septal defect, pulmonary stenosis, right ventricular hypertrophy, and overriding aorta. It was first described in detail in 1888. The physiology involves deoxygenated blood from the right ventricle being shunted away from the lungs due to pulmonary stenosis. Severity of cyanosis and murmurs depends on degree of pulmonary stenosis. Management involves treating spells and definitive surgical repair is usually done in early childhood.
Percutaneous Balloon Mitral Valvuloplasty (PBMV) is a procedure to dilated the mitral valve in the setting of rheumatic mitral valve stenosis. A catheter is inserted into the femoral vein, advanced to the right atrium and across the interatrial septum. Then the mitral valve is crossed with a balloon and it is inflated to relieve the fusion of the mitral valve commissures effectively acting to increase the mitral valve area and reduce the degree of mitral stenosis. Mitral regurgitation is a potential complication and thus PBMV is contraindicated if moderate or severe regurgitation is present. The Wilkins score examines mitral valve morphology and is determined via echocardiography to assess the likelihood of using PBMV based on certain echocardiographic criteria.
Atrial septal defect (ASD) closure can be performed surgically or percutaneously. Percutaneous closure is preferred for secundum ASDs that meet criteria such as defect size less than 38mm and adequate rim tissue. Echocardiography guides device placement and confirms closure. Complications include device embolization, arrhythmias, and erosion. Most studies report high success rates with percutaneous closure and shorter hospital stays than surgery. Surgical closure is preferred for sinus venosus, primum, or coronary sinus defects.
Single ventricle refers to congenital heart defects where there is only one functional ventricle supporting both the pulmonary and systemic circulations. There are various classifications, and the goal of treatment is to balance blood flow between the lungs and body. Initial medical management uses prostaglandins and aims for balanced pulmonary flow. Later stages involve surgical procedures like shunts, banding of arteries, and ultimately the Fontan procedure to separate circulation to the lungs and body without overloading the single ventricle. Complications can include arrhythmias, heart failure, and protein-losing enteropathy. Long term outcomes are improved with careful patient selection and multi-stage management to optimize hemodynamics at each stage.
This document discusses cardiac tamponade, which occurs when fluid rapidly accumulates in the pericardial sac, putting pressure on the heart and reducing cardiac function. Key points include:
- Pericardial effusion puts pressure on the heart, causing symptoms like chest pain and shortness of breath.
- Cardiac tamponade occurs when a rapid accumulation of fluid in the pericardial sac severely compresses the heart.
- Echocardiography is useful for diagnosing tamponade by showing findings like pericardial effusion, right ventricular collapse, and reduced respiratory variation in blood flow velocities.
- Tamponade is a medical emergency treated initially with medications and peric
I'm afraid I don't have enough information to answer these questions. The document provided is an overview of techniques for detecting intracardiac shunts and quantifying cardiac output and shunt flow. It does not include a specific patient case. Could you please provide more details about a patient for me to reference in answering your questions?
This document discusses various types of valvular heart disease, including their causes, pathophysiology, clinical manifestations, investigations, and management. It covers mitral stenosis, mitral regurgitation, mitral valve prolapse, aortic stenosis, aortic regurgitation, tricuspid stenosis, and tricuspid regurgitation. For each condition, it provides details on etiology, effects on heart function, common symptoms, diagnostic tests, medical and surgical treatment options, and patient education points.
This document discusses the embryology, anatomy, clinical presentation, evaluation, and surgical treatment of pulmonary atresia with ventricular septal defect (PA-VSD). Some key points:
- PA-VSD is characterized by atresia of the pulmonary artery and a ventricular septal defect, with pulmonary blood flow derived from collateral arteries.
- Pulmonary blood supply can be unifocal from sources like a patent ductus arteriosus or multifocal from multiple aortopulmonary collateral arteries.
- Surgical repair aims to connect as many lung segments as possible to right ventricular outflow during infancy to avoid pulmonary vascular changes, with the ultimate goal of complete repair closing all defects and incorporating
This document discusses the anatomy and electrocardiogram (ECG) patterns of different types of single ventricle heart defects. It describes 4 types - A, B, C, and D - based on the morphology and dominance of the left or right ventricle. The location of the conduction system and ECG patterns depend on factors like whether the outlet chamber is inverted or not, and the trabecular morphology. Non-inverted outlets with left ventricular dominance typically show left axis deviation on ECG, while inverted outlets with right dominance show right axis deviation. The document provides detailed descriptions of the anatomical variations and their corresponding ECG characteristics.
This document discusses atrioventricular septal defects (AVSDs), including their embryogenesis, classification, clinical features, imaging, and management. It describes the spectrum of AVSDs from partial to complete. Partial AVSDs involve a primum atrial septal defect with a cleft in the mitral valve. Complete AVSDs have a large ventricular septal defect with a common atrioventricular valve. Imaging like echocardiography is important for evaluating the anatomy and determining appropriate treatment, which ranges from observation to surgical repair.
This document discusses the Norwood procedure for treating hypoplastic left heart syndrome (HLHS). It begins with an overview of the seminar topics, including the physiology of HLHS, palliative measures, and staged surgical options. It then delves into detailed anatomy and morphology, defining HLHS and discussing major subtypes. The remainder covers clinical presentation, diagnostic testing methods like echocardiography and cardiac catheterization, and historical milestones in HLHS management.
Both the remodeling and reimplantation techniques aim to preserve the native aortic valve in patients with aortic root aneurysms. The remodeling technique involves excising the diseased sinuses and reattaching the valve within a graft, reconstructing the sinuses. The reimplantation technique reimplants the valve within a graft anchored at the aortoventricular junction. Studies have found slightly better long-term outcomes with reimplantation, especially in conditions like Marfan syndrome or dissection, though both techniques have good results. Neither technique fully restores the normal biomechanics and stress patterns of the native aortic root.
This document discusses atrioventricular canal defects (AVSDs), including their embryogenesis and pathophysiology. It describes the anatomy and classification of partial and complete AVSDs. Partial AVSDs involve a primum atrial septal defect with two distinct but contiguous AV valves, while complete AVSDs have a single common AV valve. The embryogenesis of AVSDs involves faulty development of the endocardial cushions. The document provides detailed descriptions and images of the anatomy and features of partial and complete AVSDs. It discusses the clinical aspects of AVSDs including prevalence, association with Down syndrome, surgical repair outcomes, and lifelong surveillance needs.
This document discusses atrioventricular septal defects (AVSDs). It begins with epidemiology, noting a prevalence of 4-5% of congenital heart defects. It then covers embryology, anatomy, pathology, classification, clinical features, diagnosis and management. Key points include abnormal development of endocardial cushions leading to absence of AV septum and common atrioventricular valves. Clinical features include congestive heart failure in infancy. Diagnosis is made via echocardiogram showing absent AV septum. Surgical repair aims to close defects and preserve left AV valve competence.
TGA is a complex congenital heart disease.Understanding the anatomy,physiology,surgery and anaesthetic management is very important for patient's better outcome.This ppt explains all these points in detail.
1) Atrial septal defects are one of the most common types of pre-tricuspid shunts and can often remain asymptomatic until later in life when they may lead to heart failure, pulmonary hypertension, or arrhythmias if left unrepaired.
2) The natural history and prognosis of atrial septal defects depends on factors like the size of the defect and age at diagnosis, with smaller defects having higher rates of spontaneous closure and repair at a younger age leading to better outcomes.
3) Device or surgical closure of atrial septal defects can successfully close the defect and improve symptoms, but the best outcomes are seen in those with less elevated pulmonary pressures and cardiac chamber enlargement prior to repair
SCAD is a rare, sometimes fatal, traumatic condition with approximately eighty percent of cases affecting women. The coronary artery can suddenly develop a tear, causing blood to flow between the layers which forces them apart, potentially causing a blockage of blood flow through the artery and a resulting heart attack. The condition may be related to female hormone levels, as it is often seen in post-partum women, or in women during or very near menstruation, but not always. It is not uncommon for SCAD to occur in people in good physical shape and with no known prior history of heart related illness. It is also not uncommon for SCAD to occur in people in their 20's, 30's, and 40's, as well as older.
- L-TGA, also known as corrected transposition of the great arteries, is a rare congenital heart defect where the ventricles are transposed and the atrioventricular valves are discordant.
- The embryological cause is abnormal leftward looping of the heart during development, resulting in the morphologic right ventricle being on the left side and pumping blood to the lungs, while the morphologic left ventricle is on the right side and pumps blood to the body.
- Associated abnormalities are common, including ventricular septal defects, pulmonary stenosis, tricuspid valve anomalies, and conduction system abnormalities. Long term, the right ventricle is poorly suited to function as the systemic
This document discusses peripheral pulmonary artery stenosis, including its description, associated conditions, classification, clinical features, diagnosis using imaging modalities like echocardiography and angiography, and treatment options like balloon angioplasty. Peripheral pulmonary artery stenosis can involve the main pulmonary artery or its branches and is present in 2-3% of congenital heart disease cases. Diagnosis relies on cardiac catheterization and angiography to determine severity and anatomy. Balloon angioplasty is an option for treating moderate or severe stenosis when surgery is difficult.
1) Cavopulmonary connections like the Glenn shunt divert systemic venous return directly to the pulmonary circulation, improving oxygen saturation for patients with single ventricle physiology.
2) The Glenn shunt involves anastomosis of the superior vena cava to the right pulmonary artery, reducing the volume load on the single ventricle.
3) Immediate postoperative issues include managing ventilation, elevated cavopulmonary pressures, hypertension/bradycardia, low cardiac output, and cyanosis which may result from pulmonary or systemic venous desaturation or decreased pulmonary blood flow.
An atrioventricular canal defect, also known as an endocardial cushion defect, is characterized by a complete absence of the atrioventricular septum. It results from abnormal differentiation and remodeling of endocardial cushion mesenchyme that fails to form the septal tissue. It presents with a common atrioventricular ring, a five leaflet valve guarding the common AV orifice, and an unwedged left ventricular outflow tract. Surgical repair is usually done between 2 to 4 months of age to close the septal defects and reconstruct the valves. Techniques include single patch, double patch, and modified single patch closure.
Tetralogy of Fallot (TOF) is a congenital heart defect characterized by four anatomical abnormalities - ventricular septal defect, pulmonary stenosis, right ventricular hypertrophy, and overriding aorta. It was first described in detail in 1888. The physiology involves deoxygenated blood from the right ventricle being shunted away from the lungs due to pulmonary stenosis. Severity of cyanosis and murmurs depends on degree of pulmonary stenosis. Management involves treating spells and definitive surgical repair is usually done in early childhood.
Percutaneous Balloon Mitral Valvuloplasty (PBMV) is a procedure to dilated the mitral valve in the setting of rheumatic mitral valve stenosis. A catheter is inserted into the femoral vein, advanced to the right atrium and across the interatrial septum. Then the mitral valve is crossed with a balloon and it is inflated to relieve the fusion of the mitral valve commissures effectively acting to increase the mitral valve area and reduce the degree of mitral stenosis. Mitral regurgitation is a potential complication and thus PBMV is contraindicated if moderate or severe regurgitation is present. The Wilkins score examines mitral valve morphology and is determined via echocardiography to assess the likelihood of using PBMV based on certain echocardiographic criteria.
Atrial septal defect (ASD) closure can be performed surgically or percutaneously. Percutaneous closure is preferred for secundum ASDs that meet criteria such as defect size less than 38mm and adequate rim tissue. Echocardiography guides device placement and confirms closure. Complications include device embolization, arrhythmias, and erosion. Most studies report high success rates with percutaneous closure and shorter hospital stays than surgery. Surgical closure is preferred for sinus venosus, primum, or coronary sinus defects.
Single ventricle refers to congenital heart defects where there is only one functional ventricle supporting both the pulmonary and systemic circulations. There are various classifications, and the goal of treatment is to balance blood flow between the lungs and body. Initial medical management uses prostaglandins and aims for balanced pulmonary flow. Later stages involve surgical procedures like shunts, banding of arteries, and ultimately the Fontan procedure to separate circulation to the lungs and body without overloading the single ventricle. Complications can include arrhythmias, heart failure, and protein-losing enteropathy. Long term outcomes are improved with careful patient selection and multi-stage management to optimize hemodynamics at each stage.
This document discusses cardiac tamponade, which occurs when fluid rapidly accumulates in the pericardial sac, putting pressure on the heart and reducing cardiac function. Key points include:
- Pericardial effusion puts pressure on the heart, causing symptoms like chest pain and shortness of breath.
- Cardiac tamponade occurs when a rapid accumulation of fluid in the pericardial sac severely compresses the heart.
- Echocardiography is useful for diagnosing tamponade by showing findings like pericardial effusion, right ventricular collapse, and reduced respiratory variation in blood flow velocities.
- Tamponade is a medical emergency treated initially with medications and peric
I'm afraid I don't have enough information to answer these questions. The document provided is an overview of techniques for detecting intracardiac shunts and quantifying cardiac output and shunt flow. It does not include a specific patient case. Could you please provide more details about a patient for me to reference in answering your questions?
This document discusses various types of valvular heart disease, including their causes, pathophysiology, clinical manifestations, investigations, and management. It covers mitral stenosis, mitral regurgitation, mitral valve prolapse, aortic stenosis, aortic regurgitation, tricuspid stenosis, and tricuspid regurgitation. For each condition, it provides details on etiology, effects on heart function, common symptoms, diagnostic tests, medical and surgical treatment options, and patient education points.
This document discusses various types of valvular heart disease, including causes, pathophysiology, clinical manifestations, investigations, and management. It covers the main heart valves - mitral, aortic, tricuspid and pulmonary valves. The major types of valvular abnormalities discussed are stenosis (narrowing) and regurgitation (leakage). Specific valve diseases covered in detail include rheumatic mitral stenosis, mitral regurgitation, mitral valve prolapse, aortic stenosis, aortic regurgitation, tricuspid stenosis/regurgitation, and pulmonary stenosis/regurgitation. Surgical and medical management strategies are presented for each condition. Prosthetic heart valves, both mechanical and biological,
This document discusses various types of valvular heart disease, including causes, pathophysiology, clinical manifestations, investigations, and management. It covers the main heart valves - mitral, aortic, tricuspid and pulmonary valves. The major types of valvular abnormalities discussed are stenosis (narrowing) and regurgitation (leakage). Specific valve diseases covered in detail include rheumatic mitral stenosis, mitral regurgitation, mitral valve prolapse, aortic stenosis, aortic regurgitation, tricuspid stenosis/regurgitation, and pulmonary stenosis/regurgitation. Surgical and medical management strategies are presented for each condition. Prosthetic heart valves, both mechanical and biological,
The document discusses several types of congenital heart diseases including patent ductus arteriosus (PDA), pulmonary stenosis, coarctation of the aorta, transposition of the great arteries, total anomalous pulmonary venous return, truncus arteriosus, hypoplastic left heart syndrome, and double outlet right ventricle. For each condition, it describes the anatomy, signs and symptoms, diagnosis, and management approaches including medical, catheter-based, and surgical treatments.
Pulmonary artery banding (PAB) is a palliative surgical technique used to reduce pulmonary blood flow in infants with congenital heart defects. It involves placing a band around the pulmonary artery to create stenosis and decrease blood flow to the lungs. PAB is used as an initial intervention for defects causing pulmonary overcirculation to prevent congestive heart failure and pulmonary hypertension before a definitive repair. It is also used to prepare the left ventricle in some patients with transposition of the great arteries prior to later procedures. The goal of PAB is to reduce pulmonary pressures and improve systemic circulation. It remains an important technique for staged surgical treatment of certain congenital heart conditions.
This document discusses ventricular septal defects (VSDs), including their anatomy, types, clinical presentation, diagnostic workup, and management. The key points are:
1. VSDs allow blood to pass abnormal from the left to the right ventricle. The patient presented has symptoms of a long-standing moderate VSD.
2. Echocardiography is the primary imaging modality used to characterize VSD location, size, complications like pulmonary hypertension.
3. Treatment indications for VSDs include the presence of heart failure symptoms or pulmonary hypertension. Surgical closure or catheter device closure are options.
A cyanotic heart defect is a group-type of congenital heart defects (CHDs). The patient appears blue (cyanotic), due to deoxygenated blood bypassing the lungs and entering the systemic circulation. This can be caused by right-to-left or bidirectional shunting, or malposition of the great arteries.
Cyanotic heart defects, which account for approximately 25% of all CHDs, include:
Tetralogy of Fallot (ToF)
Total anomalous pulmonary venous connection
Hypoplastic left heart syndrome (HLHS)
Transposition of the great arteries (d-TGA)
Truncus arteriosus (Persistent)
Tricuspid atresia
Interrupted aortic arch
Pulmonary atresia (PA)
Pulmonary stenosis (critical)
Eisenmenger syndrome(Reversal of Shunt due to Pulmonary Hypertension) .
Patent ductus arteriosus may cause cyanosis in late stage.
Electrocardiography in Adult Congenital Heart DiseasesSaleh AL-Hatem
The document discusses various types of congenital heart defects seen in adults, including their typical ECG presentations. For ostium secundum atrial septal defects, unrepaired defects are commonly associated with sinus rhythm on ECG, though atrial fibrillation risk increases with age. Surgical closure may reduce but not eliminate postoperative atrial arrhythmias, especially in older patients. For ventricular septal defects, ECG findings depend on the degree of left and right ventricular overload. Large unrepaired defects can cause right and left atrial enlargement and right axis deviation on ECG. Atrioventricular canal defects are associated with first-degree atrioventricular block and left axis deviation on ECG due to
Cyanotic heart disease refers to congenital heart defects that result in poorly oxygenated blood. The document discusses several types of cyanotic heart disease including Tetralogy of Fallot, Transposition of the Great Arteries, and Truncus Arteriosus. Symptoms include cyanosis, dyspnea, and hypoxic spells. Diagnosis involves clinical exams, ECGs, echocardiograms and cardiac catheterization. Treatment ranges from medical management of symptoms to surgical procedures like arterial switch operation, Fontan procedure, and shunt placements, with the goal of improving oxygen delivery and survival. Prognosis depends on the specific defect and whether corrective surgery is performed.
Valular heart disease is very common in most of Afro Asian counteries mainly due to Rheumatic heart disease..Definitive treatment is surgery.which may be valve replacement or reapir. In this ppp I have discussed this subject in a simple way
Late complications in tof and redo surgeriesbackstabber089
Risk factors for death after tetralogy of Fallot (TOF) repair include age at repair, severity of right ventricle hypoplasia, and transannular patches. Without repair, 95% of patients die by age 40 from heart failure or hypoxia. Palliative shunt procedures augment pulmonary blood flow but risk shunt closure, infection, and pulmonary issues. Late complications include pulmonary regurgitation, right heart failure, and arrhythmias. Reoperations are often needed for residual lesions or valve replacement to preserve right ventricle function. Catheter interventions can treat residual stenosis but pulmonary valve replacement may be needed for severe, symptomatic pulmonary regurgitation.
The document discusses various types of valvular heart disease, including aortic stenosis, aortic regurgitation, mitral stenosis, and mitral regurgitation. It provides details on the causes, symptoms, physical exam findings, diagnostic tests and treatments for each condition. For aortic stenosis, the case describes a 67-year-old male with symptoms of dyspnea and chest pain, who is found to have a systolic thrill and murmur, indicating severe aortic valve stenosis. Diagnostic tests and treatments are outlined for each valvular disease.
This document provides guidelines for the diagnosis and treatment of atrial septal defects (ASD), ventricular septal defects (VSD), pulmonary arterial hypertension (PAH), and anomalous pulmonary venous connections (PVC). Key recommendations include:
1. Transcatheter or surgical closure of isolated ASD or VSD is recommended for those with impaired functional capacity, enlarged right heart chambers, and net left-to-right shunt.
2. Medical management of PAH with bosentan or PDE5 inhibitors is recommended.
3. Surgical repair is recommended for partial anomalous PVC or scimitar vein to reduce right heart volume overload.
NATURAL HISTORY, HEMODYNAMICS AND SURGICAL MANAGEMENT OF AORTIC STENOSIS.pptxShivani Rao
1) Natural history, hemodynamics, and surgical management of aortic stenosis is discussed. Aortic stenosis results from various etiologies and causes a reduction in aortic valve area, increasing pressure gradients and left ventricular hypertrophy.
2) Symptoms of aortic stenosis include angina, syncope and heart failure. Surgical aortic valve replacement is recommended for severe symptomatic stenosis to improve survival. Asymptomatic patients with severe stenosis may also benefit from early surgery, particularly if the stenosis is very severe or rapidly progressing.
3) Hemodynamic parameters like aortic jet velocity and mean pressure gradient determined by echocardiography are used to classify the severity of aortic stenosis and guide
Adult Congenital Heart Disease can affect over 1 million adults in the US. Common conditions include Atrial Septal Defects, Ventricular Septal Defects, Patent Ductus Arteriosus, Bicuspid Aortic Valve, Coarctation of the Aorta, Tetralogy of Fallot, and Transposition of the Great Arteries. Clinical presentation and treatment depends on the specific condition and degree of severity. Long term monitoring is important for complications. Pregnancy can also pose additional risks for some congenital heart conditions.
This document provides information on transposition of the great arteries (TGA), including its definition, theories of development, morphology, clinical features, diagnosis, and management. Some key points:
- TGA is a congenital heart defect where the aorta arises from the right ventricle and the pulmonary artery arises from the left ventricle, rather than their normal positions.
- There are several theories for its development during embryogenesis. Its morphology involves abnormalities in the ventricles, arteries, valves, and other structures compared to normal.
- Presentation depends on mixing between circulations. Poor mixing in infants with intact septum leads to severe cyanosis. Better mixing with a VSD or P
Single ventricle physiology involves a heart with only one functional pumping chamber. The document discusses the anatomy, physiology, and surgical management of various types of single ventricle hearts. Key points include: the goal of initial surgery is to provide unobstructed systemic outflow and pulmonary blood flow while limiting pulmonary pressures; manipulation of pulmonary and systemic vascular resistances is important for balancing blood flow; and inotropic support can increase cardiac output while adjusting pulmonary to systemic flow ratios.
1. Most common cardiac conduction abnormalities during CVC insertion are right bundle branch blocks and new left anterior and posterior fascicular blocks which result from overzealous advancement of the guide wire.
2. The most common site of catheter-related deep vein thrombosis is the internal jugular vein. Risk factors include history of DVT, subclavian insertion site, and improper catheter tip positioning.
3. Symptoms of venous air embolism during CVC insertion include chest pain, dyspnea, headache, EKG changes, and decreased cardiac output. Treatment involves stopping air entry, placing the patient in Trendelenburg and left lateral position, and
How to recognise and manage idiopathic ventricular tachycardia (nhịp nhanh thất)SoM
This document summarizes common forms of idiopathic ventricular tachycardia. It discusses how right ventricular outflow tract VT and left ventricular outflow tract VT are the most common forms, often presenting as nonsustained, repetitive monomorphic VT in younger patients. Treatment may include medications like beta-blockers or verapamil, but catheter ablation has over a 90% success rate. Distinguishing idiopathic VT from other conditions is important as treatment differs. The prognosis is generally excellent for idiopathic VT patients.
This document discusses weaning from mechanical ventilation. It defines key terms like liberation, extubation, spontaneous breathing trials (SBT), and weaning success and failure. It describes the process of conducting an SBT to assess readiness for extubation. Factors that can lead to weaning failure like respiratory load, cardiac load, neuromuscular issues, and psychological factors are reviewed. Finally, it discusses using different ventilator modes like pressure support ventilation to aid in more difficult weaning cases.
Tracheostomy is an artificial opening created in the trachea in the neck to allow access to the lower airway. It has major indications for preventing laryngeal damage from prolonged intubation, managing secretions, and providing stable airway access for prolonged mechanical ventilation. The techniques include open surgical and percutaneous dilatational tracheostomy. Early tracheostomy within 7 days of cardiac surgery has been shown to improve outcomes compared to late tracheostomy by reducing atrial fibrillation, kidney dysfunction, ICU stay, and hospital stay with no increase in mortality or infections. Complications can occur during surgery or post-operatively including hemorrhage, pneumothorax, nerve injury, and infections. Care involves tube
1. This document provides protocols for ventilator settings for adults, children aged 1-10 years, and neonates/infants. It includes guidelines for initial settings, adjusting settings based on blood gas results, criteria for weaning and extubation.
2. The protocol outlines steps for changing settings from initial pressure-regulated volume control (PRVC) to synchronized intermittent mandatory ventilation (SIMV) and lists criteria for determining readiness for a spontaneous breathing trial.
3. Special considerations are provided for various clinical situations like post-cardiac surgery patients, pulmonary issues, and open sternum cases.
This document defines infective endocarditis and discusses its pathogenesis, clinical features, diagnosis, treatment and complications. Some key points:
- Infective endocarditis is defined as an infection of the endocardial surface of the heart, including heart valves. It most commonly affects the atrial side of the AV valves and ventricular side of semilunar valves.
- Staphylococcus aureus is now the most common causative organism, whereas streptococci were previously more common. Risk factors include underlying heart conditions, intravenous drug use, and invasive procedures.
- Clinical features include fever, heart murmur, embolic events, and immunological findings like Roth spots and Osler nodes
This document provides an overview of intra-aortic balloon counterpulsation (IABP). It discusses the history and physiological effects of IABP, including increasing coronary perfusion and decreasing cardiac work. Indications for IABP include acute myocardial infarction and cardiogenic shock. The document reviews IABP instrumentation, monitoring, waveforms, timing, complications, weaning, and removal. IABP is a temporary circulatory support device that aims to improve heart function through counterpulsation.
This document discusses various laboratory tests used to monitor coagulation, including clotting time, prothrombin time and INR, activated partial thromboplastin time, fibrinogen level, fibrin degradation products, D-dimer, and tests for monitoring anticoagulants like heparin. It provides details on what each test measures, its normal range and clinical uses, and potential causes of abnormal results. It also discusses limitations and factors that can influence certain tests, as well as newer techniques for individualized monitoring and dosing of heparin.
This document discusses coronary artery anomalies associated with congenital heart disease. It notes that coronary anomalies can be associated with or due to congenital heart diseases like tetralogy of Fallot, transposition of the great arteries, truncus arteriosus, and pulmonary atresia with intact ventricular septum. It provides details on common coronary artery patterns and surgical management options for addressing anomalous coronary arteries during repair of various congenital heart defects.
1. The document describes a case of a 28-year-old female with cyanotic congenital heart disease who underwent an arterial switch operation with integrated ECMO support.
2. ECMO is a form of extracorporeal life support used for both cardiac and respiratory failure in adults. It involves pumping blood out of the body to an artificial lung for gas exchange before returning it to circulation.
3. The key components of an ECMO circuit include a blood pump, membrane oxygenator, tubing, heat exchanger, and monitoring equipment. Proper anticoagulation and flow rates are important for safety and effectiveness.
Evolution of management stratergy for TGAIndia CTVS
This document discusses the evolution of surgical management strategies for transposition of the great arteries (TGA). Early palliative procedures like atrial septectomy had high mortality. The atrial switch procedures (Senning and Mustard) developed in the 1950s-60s provided longer term survival but were associated with complications like arrhythmias, systemic ventricular dysfunction, and obstruction of venous pathways. The arterial switch operation developed in 1975 revolutionized treatment by anatomically correcting the defect. However, early attempts were unsuccessful due to technical challenges like coronary artery transfer. The landmark successful case by Jatene in 1975 established the arterial switch as the standard of care for TGA, though early mortality rates were still high at some centers. Long term
This document discusses heart transplantation, including indications, donor and recipient criteria. It provides a brief history of heart transplantation from early experiments to modern procedures. Key points include common indications for transplant like dilated cardiomyopathy, the importance of matching donor and recipient size and blood type, and selecting recipients without other medical issues that could impact outcomes. Contraindications and special considerations for procedures like ABO incompatible and pediatric transplants are also summarized.
Hypoplastic left heart syndrome (HLHS) is characterized by underdevelopment of the left side of the heart. It requires multi-stage surgical intervention to establish an adequate circulation. The first stage, known as the Norwood procedure, involves reconstructing the aortic arch and creating a shunt to provide pulmonary blood flow. Subsequent stages include the hemi-Fontan/Glenn procedure and final Fontan completion. Alternative treatments include heart transplantation or hybrid approaches. Long-term survival has improved but remains dependent on surgical expertise and individual patient risk factors. Ongoing management focuses on achieving balanced systemic and pulmonary circulations through each stage of treatment.
Pumps, oxygenators, and priming solutions are essential components of cardiopulmonary bypass. There are two main types of pumps - roller pumps and centrifugal pumps. Roller pumps work by rolling blood through tubing while centrifugal pumps use centrifugal force to move blood. Membrane oxygenators allow for gas exchange through a semi-permeable barrier, separating blood from gas, and eliminating the damage caused by bubble oxygenators. Proper selection of the components depends on factors such as flow needs, biocompatibility and minimizing trauma to blood during bypass.
This document discusses red blood cell and component therapy. It covers three pillars of patient blood management: preoperative detection of anemia, intraoperative hemostasis and cell salvage, and postoperative optimization. It then describes the components that make up component therapy, including packed red blood cells (PRBC), platelets, fresh frozen plasma, cryoprecipitate, and leukoreduced and irradiated PRBCs. Indications for transfusion and potential complications are also summarized.
1. The document outlines the history and evolution of surgical techniques for treating transposition of the great arteries (TGA).
2. Early techniques included atrial septal defect creation (Blalock-Hanlon) and atrial switch operations by Senning and Mustard using flaps or baffles.
3. The arterial switch operation was first successfully performed by Jatene in 1975 and modified by Lecompte, allowing coronary artery transfer.
4. Advances now allow arterial switch in neonates and extended to 6 months with support like ECMO.
This document discusses pediatric extracorporeal membrane oxygenation (ECMO) management including:
- Types of ECMO including venovenous and venoarterial
- Ventilator, coagulation, nutrition, inotrope, and sedation management of children on ECMO
- Monitoring of vital signs and investigations including echocardiograms and blood work
- Guidelines for weaning children from ECMO when stable and meeting criteria
- Potential complications of ECMO like bleeding, infection, and neurological injury and their management
- Procedures that can be done while a child is on ECMO
This document discusses the diagnosis and management of total anomalous pulmonary venous connection (TAPVC). It covers the types of TAPVC, diagnostic tools including ECG, CXR, echocardiography and catheterization, and surgical and interventional treatment options. The key points are:
1. TAPVC is diagnosed using imaging modalities like echocardiography, CT, and catheterization to identify the anomalous pulmonary vein drainage.
2. Surgical repair is the definitive treatment and involves anastomosis of the pulmonary veins to the left atrium. Factors like age, type of TAPVC, and presence of obstruction determine timing of surgery.
3. Post-operative management focuses on stabil
This document discusses the pathophysiology of constrictive pericarditis (CCP). CCP is caused by a thickened and fibrotic pericardium that restricts heart filling. This leads to 4 key hemodynamic changes: 1) impaired diastolic filling, 2) dissociation of intrathoracic and intracardiac pressures with respiration, 3) excessive ventricular coupling, and 4) heart rate dependent filling. The thick pericardium equalizes pressures in all chambers and abruptly halts early diastolic filling. Inspiration decreases left ventricular filling while increasing right ventricular filling via septal shift. Expiration causes the opposite effect.
This document discusses the history and evolution of mechanical heart valve substitutes from the 1950s to the present. It describes early ball and cage valves developed by Harken and Starr-Edwards in the 1950s-60s that helped ignite the field of prosthetic heart valves but had limitations. It then covers the development of tilting disc valves including the Bjork-Shiley valve that was later recalled due to failures, and bileaflet valves such as the St. Jude Medical valve made of durable pyrolytic carbon. The document traces the materials, designs and improvements made to mechanical heart valves over decades to increase effectiveness and safety.
This document provides a history of heart valve substitutes, beginning with the first implantation of homografts in the 1950s-1960s and moving to the development of xenograft valves fixed with glutaraldehyde in the 1960s-1970s. It discusses the work of Carpentier in developing low-pressure fixation and mechanical protection of valves. Various generations of bioprosthetic valves are summarized, including advances in fixation methods and anti-mineralization treatments. Stentless valves are introduced, providing improved hemodynamics over stented valves but requiring more complex implantation.
1. Ventricular septal defects (VSDs) are one of the most common congenital heart defects, accounting for 20-30% of cases in India.
2. The natural history and progression of a VSD depends on factors like its size, location, and the development of pulmonary hypertension.
3. Small VSDs have over a 50% chance of spontaneous closure by age 5, while larger defects often require surgical intervention. Without treatment, complications can include congestive heart failure, pulmonary vascular disease, bacterial endocarditis, and aortic regurgitation.
Muktapishti is a traditional Ayurvedic preparation made from Shoditha Mukta (Purified Pearl), is believed to help regulate thyroid function and reduce symptoms of hyperthyroidism due to its cooling and balancing properties. Clinical evidence on its efficacy remains limited, necessitating further research to validate its therapeutic benefits.
Basavarajeeyam is a Sreshta Sangraha grantha (Compiled book ), written by Neelkanta kotturu Basavaraja Virachita. It contains 25 Prakaranas, First 24 Chapters related to Rogas& 25th to Rasadravyas.
Promoting Wellbeing - Applied Social Psychology - Psychology SuperNotesPsychoTech Services
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Cell Therapy Expansion and Challenges in Autoimmune DiseaseHealth Advances
There is increasing confidence that cell therapies will soon play a role in the treatment of autoimmune disorders, but the extent of this impact remains to be seen. Early readouts on autologous CAR-Ts in lupus are encouraging, but manufacturing and cost limitations are likely to restrict access to highly refractory patients. Allogeneic CAR-Ts have the potential to broaden access to earlier lines of treatment due to their inherent cost benefits, however they will need to demonstrate comparable or improved efficacy to established modalities.
In addition to infrastructure and capacity constraints, CAR-Ts face a very different risk-benefit dynamic in autoimmune compared to oncology, highlighting the need for tolerable therapies with low adverse event risk. CAR-NK and Treg-based therapies are also being developed in certain autoimmune disorders and may demonstrate favorable safety profiles. Several novel non-cell therapies such as bispecific antibodies, nanobodies, and RNAi drugs, may also offer future alternative competitive solutions with variable value propositions.
Widespread adoption of cell therapies will not only require strong efficacy and safety data, but also adapted pricing and access strategies. At oncology-based price points, CAR-Ts are unlikely to achieve broad market access in autoimmune disorders, with eligible patient populations that are potentially orders of magnitude greater than the number of currently addressable cancer patients. Developers have made strides towards reducing cell therapy COGS while improving manufacturing efficiency, but payors will inevitably restrict access until more sustainable pricing is achieved.
Despite these headwinds, industry leaders and investors remain confident that cell therapies are poised to address significant unmet need in patients suffering from autoimmune disorders. However, the extent of this impact on the treatment landscape remains to be seen, as the industry rapidly approaches an inflection point.
share - Lions, tigers, AI and health misinformation, oh my!.pptxTina Purnat
• Pitfalls and pivots needed to use AI effectively in public health
• Evidence-based strategies to address health misinformation effectively
• Building trust with communities online and offline
• Equipping health professionals to address questions, concerns and health misinformation
• Assessing risk and mitigating harm from adverse health narratives in communities, health workforce and health system
2. Clinical features
• Depends on associated anomalies
• Vsd – 80%
– Only in 20% increased pulmonary blood flow (PBF)
– With some degree of ps
– Variable presentation
– Rarerly in infancy – cyanosis
– Chilhood or 2nd decade
– 3,4,5 th decades with rv (systemic ventricular) failure
3. • Clinical features
• Complete heart block is the most common
arrhythmia in patients with L-TGA with signs and
symptoms of bradycardia, fatigue, and poor exercise
tolerance.
• Progressive fibrosis of conduction system with
advancing age, which increases the risk of complete
heart block (progressive incidence of 2 percent per
year ) and re-entrant tachyarrhythmias including
Wolff-Parkinson-White (WPW) syndrome.
4. • Unoperated Natural History
• Early natural history is significantly affected by the severity of
associated lesions and surgical management.
• Although there have been repeated case reports of long-term
survival with ccTGA, this is likely unusual .
• Beauchesne et al. followed 44 unoperated patients for 144
months and found that most (59%) had grade 3 or greater
systemic atrioventricular valve regurgitation and that many of
these demonstrated significant systemic RV dysfunction and
were symptomatic.
5. • Presbitero et al. have followed 18 patients, again pointing to
systemic atrioventricular valve regurgitation and ventricular
dysfunction as major concerns.
• Graham et al. In a large multi-institutional study, found that,
patients without associated lesions had a lower occurrence
rate of heart failure and systemic ventricular dysfunction than
those with associated lesions at a given age, these problems
tended to increase in frequency with advancing age in both
groups.
6.
7. • Electrocardiography —
• In L-TGA, the interventricular septum is depolarized in the
opposite direction of normal.
• Q waves in the right precordial leads and an absence of Q
waves in the left-sided precordial leads
• These electrocardiographic findings may be misinterpreted as
an inferior myocardial infarction
• In addition, patients may also have varying degrees of AV
heart block due to abnormalities of the conduction system.
• As noted above, the risk of CHB rises over time with a 2
percent per year increase in incidence
8.
9. • Chest radiograph —
• 25 % of patients with L-TGA will have mesocardia or
dextrocardia
• In those patients with levocardia (normal location),
the leftward positioned aorta usually results in a
prominence in the upper left border of the
mediastinum
10. congenitally corrected transposition of the great arteries, a nonrestrictive
ventricular septal defect, and increased pulmonary blood flow.
A septal notch (unmarked arrow, lower right) appears just above the left
hemidiaphragm.
The ascending aorta (AAo) is convex at the left base,
the dilated posterior pulmonary trunk causes rightward displacement of
the superior vena cava (SVC).
11. echocardiography
• Atrial situs solitus
• Atrio ventricular discordance
• Lt sided av - valve more towards apex
• Direct chordal attachments to septum
• Coarse trabeculated endocardial surface of ventricle
to left side
• Ventriculo arterial discordance
• Rt av - valve and pulmonary valve in continuity
• Presence of associated anomalies
13. Angiography
• Profile septum
• Location and no of vsd’s
• Nature of ps
• Tricuspid valve fn
• Measure PVRI
• Shunt fraction
• Ventricular edp.
14. • Medical Management
• Medical management involves the usual modalities
for cardiac failure, such as inhibition of angiotensin-
converting enzymes, diuretics, and control of
arrhythmias with pacing to raise the heart rate when
necessary.
15. Indications for intervention in CC-TGA
The presence of corrected TGA is not an indication for a
reparative operation
WITHOUT ASSOCIATED DEFECTS
Complete heart block
-WITH ASSOCIATED DFECTS
1. Ventricular septal defect
2. VSD & Important PS
3. Left-sided tricuspid incompetence
16. • CHB
• Dual chamber AV sequential pacemeker is indicated in any
symptomatic patient with AV block.
17. • CORRECTIVE SURGICAL MANAGEMENT
• Overview — There has been a paradigm shift from
• conventional repair/Physiological Repair of the associated cardiac lesions
while maintaining the congenitally corrected atrioventricular and
ventriculoarterial discordance to an
• “anatomic” repair, which makes the morphologic left ventricle become
the systemic pump and the morphologic right ventricle the pulmonary
ventricle.
18. • Isolated L-TGA –
• the choice of anatomic repair is controversial.
• complex procedures that require substantial time on bypass .
• In contrast, there are data that show adults with isolated L-TGA without
anatomic repair are at-risk for systemic heart failure, although the risk is
lower than patients described above with associated lesions .
The final decision is individualized based on a review of the patient’s
potential for heart failure without anatomic correction versus the
potential complications of the anatomic repair, and the preference of the
family.
19. • Suggested guide for deciding surgical approach
• Pediatric patients with L-TGA and
– significant ventricular septal defect [VSD],
– left ventricular (LV) outflow tract obstruction, and/or
– Ebstein-like malformation of the tricuspid valve
• should be considered for anatomic repair as they are at greatest risk for
developing systemic heart failure with conventional repair.
•
20. • Patients who are diagnosed with L-TGA beyond childhood eventually
present with systemic ventricular dysfunction or failure, systemic tricuspid
valve regurgitation, or arrhythmias.
• When systemic tricuspid regurgitation is present, these adults should be
referred for systemic AV valve replacement before they have morphologic
right ventricular failure or progressive dysfunction (systemic right
ventricular EF less than 40 percent).
• PA banding has been found to improve systemic AV valve regurgitation in
select patients.
• Cardiac transplantation or ventricular assist device placement should be
considered in patients with persistent heart failure refractory to these
measures and medical management.
21. • conventional repair/Physiological Repair
• Associated cardiac anomalies can be repaired with this approach, albeit
that the morphologically right ventricle remains as the pump to the
systemic circulation.
– ventricular septal defects, if present, can be closed,
– obstruction within the left ventricular outflow tract can be relieved by
either resection or placement of a valved conduit, and the
– tricuspid valve, if leaking, can be repaired or replaced.
22. • ventricular septal defect
• Usually the VSD is perimembranous in position-
• NO right ventriculuotomy and no damage to systemic av valve
- incision in the right atrium,, through the morphologically mitral valve either
displacing septal leaflet or cutting the annulus .
• Some muscular outlet defects can be
– closed via the pulmonary trunk and the pulmonary valve.
• The conduction system passes in anterocephalad fashion around the
pulmonary outflow tract.
• To avoid damaging the conduction system, either continuous or interrupted
sutures are placed on the morphologically right ventricular margin of the
defect superiorly, and from the morphologically left ventricular side of the
margin inferiorly
• PA banding to prevent pulomonary overcirculation and PAH –May help for
anatomic repair in future.
23. • LVOTO
• Mostly subvalvular posteriorly located overlied by RV anteriorly.
• Conduction system runs on left ventricular side of septum- any tension on
septum can damage it.
• Incisions placed across the attachments of the pulmonary valvar leaflets
• the ventriculotomy is placed towards the apex of the ventricle
– careful resection of accessory tissue, or
– open pulmonary valvotomy, but in general
– a valved conduit is placed from the morphologically left ventricle to
the pulmonary arteries so as to relieve the obstruction.
• Valved conduits will not last forever, and most will need to be changed.
• It is wise, therefore, to close the pericardium with a membrane to protect
the heart during sternal re-entry at reoperations.
24. • Morphologically tricuspid valve abnormalities
• Repair or replacement of the morphologically tricuspid valve sometimes
has to be done as part of physiological repairs when there is severe
tricuspid valvar regurgitation.
• with problems of continuing cardiac failure, since often the
morphologically right ventricle is failing by the time such surgery is
entertained.
• In addition, particularly in younger patients where there is marked
dysplasia of the valvar leaflets, repair can be extremely difficult, if not
impossible.
• Under these circumstances, replacement may well be necessary.
• Difficulties are Similar to ebstein anamoly
25. Classic Operation of CC-TGA
1. Repair of ventricular septal defect
2. Repair of coexisting VSD & PS
· Extracardiac conduit
· Without extracardiac conduit
3. Correction of incompetent tricuspid valve
· Repair ( annuloplasty )
· Replacement
4. Fontan-type repair
Straddling, A-V canal , hypoplastic ventricle
26. INDICATIONS FOR OPERATION
• CCTGA per se is not a definitive indication for a reparative operation.
• When VSD coexists.
• When VSD and important pulmonary stenosis coexist
• When important left-sided tricuspid regurgitation coexists
• When complete heart block develops
• (1) presence of straddling tricuspid chordae (increasing risk of
postoperative complete heart block), (2) AV septal defect, and (3)
presence of left-sided tricuspid regurgitation may be considered by some
to be indications for a Fontan, rather than biventricular repair.
27. Repair of Coexisting Ventricular
Septal Defect
• Preparations for operation, median sternotomy, and placing pericardial
stay sutures are as usual.
• It is done where the large VSD is only associated anomaly and it keeps RV
as systemic ventricle and has disadvantage of increased incidences of late
RV failure.
• Different approaches to repair the VSD includes:
1. Through Right-Sided Mitral Valve
2. Through Aorta
3. Through Left-Sided Tricuspid Valve
28.
29. Through Right-Sided Mitral Valve
• Cardiopulmonary bypass (CPB) is established in the usual manner.
• The right atrium is opened through an oblique incision.
• The VSD is examined through the right-sided mitral valve.
• When exposure is suboptimal, an incision is made in the base of the mitral
valve septal leaflet near the superior commissure and through the base of
the commissural tissue into the mural leaflet.
• Location of anterior AV node and bundle of His arching over the
subpulmonary outflow tract and passing anterior to the VSD are
conceptualized.
• VSD repair is made by sewing into place a properly sized patch of either
glutaraldehyde-treated autologous pericardium or double-velour-knitted
polyester, keeping sutures on left (RV) side of defect anterosuperiorly,
anteriorly, and as much as possible inferiorly.
30.
31.
32. Through Aorta
• An attractive alternative approach is closing the VSD through the aorta,
which allows the patch to be sutured into place from the RV (left-sided)
aspect of the septum.
• this may reduce prevalence of perioperative complete heart block.
33. Through Left-Sided Tricuspid Valve
• When isolated dextrocardia complicates CCTGA and VSD, the VSD can be
repaired through a left-sided incision in the usually large left-sided left
atrium.
• Exposure through the left-sided tricuspid valve usually allows good
exposure, and surgically induced heart block should be avoidable because
suturing is all on the RV (left) side of the septum.
34. Repair of Coexisting Ventricular Septal
Defect and Pulmonary Stenosis
• valvotomy is performed as for isolated pulmonary valve stenosis .
• Obstructing fibrous subvalvar tags are excised.
• A subvalvar fibrous membrane can be excised, except at the
anteroinferior angle.
• Aneurysm of the membranous ventricular septum is excised and the
deficiency closed as part of VSD repair.
• Muscle must never be removed from the rightward (medial) aspect of the
right-sided LV outflow tract or from the anterior part adjacent to the
pulmonary "anulus," because the His bundle lies there.
35. • it has seemed reasonable not to revert to CPB and place a valved
extracardiac conduit if the PLV/RV in operating room is less than about
0.85, considering that the right-sided ventricle and valve are a
morphologic LV and mitral valve.
36. Placing Valved Extracardiac Conduit
• When pulmonary stenosis is so severe that the
patient is cyanotic
• if simple procedures are unsatisfactory or
postrepair PLV/RV is too high, a valved
extracardiac conduit is used.
37. • a site is chosen for attaching the conduit to the right-sided LV by
examining the LV interior through the mitral valve. A site is chosen on the
anterior wall, but rather inferior and away from any papillary muscles. Left
ventriculotomy is then made.
• There is reasonable flow across the native LV-pulmonary trunk outflow
tract, it can be left intact, creating an end-to side anastomosis of conduit
to pulmonary trunk. This results in LV ejection via two routes: native tract
and conduit.
• More commonly, when a conduit is required, obstruction is severe;
therefore the pulmonary trunk is transected at the valve level, proximal
stump oversewn, and conduit connected end to end to distal pulmonary
trunk.
38.
39. • Estimating length and lie of the conduit is important to avoid its
compression by the sternum.
• the conduit must be of sufficient length to prevent kinking, and the valve
must lie away from the LV so it is not distorted.
• The conduit curves to the right around the right atrium and atrial
appendage.
• Typically conduit is positioned to right side of the midline and ascending
aorta.
• A composite conduit is usually constructed using a distal valved allograft
and a proximal polytetrafluoroethylene or polyester tube.
• Distal position of valved conduit component within the composite allows
the valve to be positioned more posteriorly in mediastinum, thereby
avoiding compression and distortion of valve with sternal closure.
40. Transanular Patch
• Doty and colleagues have proposed using a posteriorly placed transanular
patch across the pulmonary valve "anulus“ in this situation.
• average gradient across the repair was 40 mmHg.
41. Correction for Regurgitant Left-Sided
Tricuspid Valve
• When important left-sided tricuspid valve regurgitation coexists, repair
and anuloplasty are only occasionally successful, but should be attempted
if it seems feasible.
• Valve replacement is the same as for a left-sided mitral valve.
• The replacement device is either sewn in with interrupted pledgeted
mattress sutures or simple interrupted sutures. A continuous suture
technique is not desirable when there is absence of a welldefined anulus.
43. Morphologic Right Ventricle
Supporting Systemic Circulation.
• Early (hospital) death:
• for CCTGA and VSD, hospital mortality has been 5% or less .
• When performed for CCTGA with coexisting VSD and important
pulmonary stenosis, it has been 10% to 20%.
• When performed for coexisting left-sided tricuspid valvar regurgitation
requiring valve replacement, it has been 15% to 25%.
44.
45. • Anatomic repair —
• Associated lesions remains the major determinant regarding surgical
repair.
• The poor late outcome results associated with conventional repair of L-TGA
has led to anatomic correction to make the morphologic LV the systemic
pump and the morphologic RV the pulmonary ventricle.
46. 1. Morphologic LV that is prepared (ie, sufficiently hypertrophied or
“trained”) to take over the workload of the systemic ventricle,
thereby minimizing the likelihood of postoperative LV failure.
2. Current LV/RV pressure ratio greater than 0.7
3. Unobstructed LV-PA & RV-Ao connections
4. Balanced ventricular & AV valve sizes
5. Septatable heart, without AV valve straddling
6. Translocatable coronary arteries
7. Competent mitral valve with good LV function
(Karl TR, et al. ATS 1997)
Proposed Patient Selection Criteria
47. • Anatomical Correction
• The current choice of surgical intervention for anatomic correction of the
ventricles is largely dependent on the
– presence of subpulmonary obstruction and the
– anatomy of the VSD:
• morphologically left ventricle is restored to pumping the systemic
circulation by
– double-switch operation-combining atrial and arterial switch
procedures, or
– atrial switch along with ventricular rerouting.
48. • Double -switch operation
– Where competent and non-stenotic valves.
• Atrial switch along with ventricular rerouting/ Senning-Rastelli procedure.
– Where there is pulmonary stenosis or atresia, usually in association
with a large ventricular septal defect, the atrial switch is combined
with tunnelling of the morphologically left ventricle to the aorta.
– A valved conduit is then placed from the morphologically right
ventricle to the pulmonary arteries.
49. • Pulmonary artery banding or left ventricular “training” —
• Not needed in significant PS/pulmonaryhypertension/unrestrictive VSD.
• In these patients, the LV is already functioning at pressure levels
consistent with what will be required as the systemic ventricle.
• However, in other patients in whom the LV is not initially ready to become
the systemic ventricle, PA banding is used to “train” the LV.
50. • Pulmonary artery banding or left ventricular “training” —
• In L-TGA patients with a LV that is not ready to function as the systemic
ventricle, placement of a band on the pulmonary artery (PA) is used to
increase the afterload of the morphologic LV.
• This exposure to near systemic pressure increases the LV posterior wall
thickness (ie, left ventricular “training”).
• Altering the left and right ventricular pressure ratio may also reduce the
right ventricular sphericity and improve the geometry of the right ventricle
prior to anatomic correction .
51. • Although pediatric cardiac surgical centers use varying measurements to
determine if a morphologic LV is adequately prepared for the systemic
circulation, most published reports suggest a morphologic LV pressure of
66 to 80 percent of systemic pressure is sufficient.
• In addition, others recommend that normal LV mass and thickness for
systemic function using echocardiography and/or magnetic resonance
imaging be required prior to anatomic correction .
• Risk factors for failure of PA band retraining include
– mild LV dysfunction before banding,
– development of significant LV dilation and dysfunction, and
– postoperative development of tricuspid regurgitation .
52. • In several case series, the median time from PA banding to the double
switch procedure ranged from 2 to 14.5 months .
• Typically, PA banding appears to be more successful in patients less than
13 years of age, and the younger the patient, the shorter interval required
for training.
• Patients older than 16 years of age appear to be unlikely to achieve
sufficient LV function to proceed to anatomic correction.
53. • Pulmonary artery banding for Large ventricular septal defect —
• In infants with a large unrestrictive VSD, an increase in pulmonary blood
flow may result in heart failure in the first few weeks of life as the
pulmonary vascular resistance falls.
• The placement of a PA band can be considered in patients who are
refractory to medical management.
• Creating increased resistance to the pulmonary circuit will reduce
pulmonary blood flow, improve the symptoms of heart failure, and
promote weight gain.
• Promotion of growth is desired as anatomic surgical correction is easier to
perform in a larger infant.
54. • Double switch operation —
• The double switch (DS) operation
consists of an atrial switch procedure
that creates an intra-atrial baffle
(Mustard or Senning procedure) and an
arterial switch operation (ASO).
• The intra-atrial baffle diverts the
deoxygenated systemic venous return
into the subpulmonary ventricle and
oxygenated pulmonary venous return
to the subsystemic ventricle.
• The ASO involves transection of both
great arteries, and then translocation of
the vessels to the opposite root similar
to the ASO procedure performed for D-
TGA requiring coronary artery transfer.
55. • Relocation of the pulmonary trunk may be achieved by transposing the
pulmonary arteries anterior to the reconstructed aorta, or they may be
left in posterior position.
• In general, if the aorta is more or less anterior to the pulmonary trunk,
then the pulmonary arteries are relocated anteriorly.
• If the arterial trunks are more side-by-side, then we leave the pulmonary
arteries behind the newly reconstructed aorta.
• At the end of the procedure, it is important to check on the reconstruction
using transoesphageal or epicardial echocardiography, confirming the
patency of the venous and arterial pathways as well as ensuring adequate
ventricular function
56. • After a DS procedure, normal concordance is established with systemic
deoxygenated blood baffled across the tricuspid valve into the
morphologic right ventricle and flow into the pulmonary artery.
• In addition, the oxygenated pulmonary venous return is baffled from the
left atrium across the mitral valve into the morphologic left ventricle and
then pumped across the neo-aorta to the systemic circulation
57. • This operation is a technically difficult and challenging procedure with a
long cardiopulmonary bypass time.
• Therefore, identifying the ideal surgical timing is a complex issue.
• Various centers report a median age at the time of surgery that ranges
from 7 months to 3.2 years and a median weight of 9.6 to 14.7 kg.
• Early hospital mortality is reported to range from 0 to 7.4 percent, and
reported event-free survival rates are between 70 to 85 percent at 10
years .
• In addition, coronary artery transfer is required. As a result, in patients
undergoing this surgical intervention, delineating the coronary anatomy is
mandatory.
58. • Senning-Rastelli procedure —
• In patients with L-TGA that have a VSD and LV outflow tract obstruction,
the Senning-Rastelli (SR) procedure is typically used.
• In this intervention, the intra-atrial baffle (Senning tunnel) is created and a
baffle is placed in VSD so that the blood from the LV is directed into the
aorta, and a conduit is placed between the right ventricle and pulmonary
artery (Rastelli procedure).
• The Rastelli procedure requires a sizable and appropriately located VSD so
that the baffle can be placed to redirect blood flow into the aorta.
• The intermediate-term results show improved survival of this group
compared with the patients undergoing a double switch operation same
used for D-TGA, VSD, and LV outflow tract obstruction.
• Long-term, conduits become stenotic as they do not grow as the child
grows. As a result, patients who undergo a Senning-Rastelli procedure
require serial conduit replacements.
59. • Ventricular Rerouting Combined
with Atrial Redirection
• The atrial switch is performed in
the same manor as for the double-
switch procedure
• An incision is made in the
morphologically right ventricle,
permitting creation of an
intraventricular tunnel between the
ventricular septal defect and the
aorta.
• In creating this tunnel, care has to
be taken to avoid any subaortic
stenosis.
• The repair is completed by placing
a valved conduit from the right
ventriculotomy to the pulmonary
arteries.
60. • Outcome and complications — Because these procedures were initially
introduced in the 1990s, there are limited long-term outcome data.
Nevertheless, several case series have provided information regarding
mortality and morbidity.
• Mortality —
• The following case series demonstrate comparable mortality rates to that
seen with conventional repair. It remains to be seen if long-term survival
improves
• In a large case series of 113 patients from an English pediatric cardiac
surgical center of patients undergoing anatomic repair from 1991 to 2011,
actuarial survivals at 1, 5, and 10 years were 88, 84, and 84 percent in the
DS group (n = 68), and 92, 92, and 77 percent in the SR group (n = 45),
respectively .
• Early deaths occurred in five patients in the DS group, and no patients in
the SR group
61. • Morbidity —
• The complications associated with anatomic correction in patients with L-
TGA are primarily due to conduction abnormalities (ie, complete heart
block and arrhythmias), left ventricular dysfunction, and neo-aortic
regurgitation.
• In addition, some of the baffle-associated complications seen in patients
with D-TGA who undergo ASO repair may also occur in patients with L-TGA
who undergo DS operation.
62. • Conduction abnormalities —
• New onset complete heart block and atrial arrhythmias are common
complications postoperatively .
• In the previously mentioned English case series of 113 patients.
• After anatomic correction, pacemaker insertion was required in 10 of the
68 patients who underwent DS and in 5 of the 45 patients with SR
procedure. In this cohort, tachyarrhythmias were observed in four patients
preoperatively and developed in four patients postoperatively (three in
the DS group and one in the SR group).
63. • Left ventricular dysfunction — .
• Morphologic LV dysfunction -reported in 14 to 18 percent of patients .
• Due to the small numbers of patients, it is currently difficult to determine
with certainty the underlying cause or risk factors of postoperative LV
dysfunction.
• In the previously mentioned English case series, 16 of the 113 patients (14
percent) developed LV dysfunction postoperatively, all of whom were in
the DS group .
64. • Neo-aortic regurgitation —
• Patients who have undergone DS appear to be at greater risk for neo-
aortic regurgitation than patients who have undergone SR procedure.
• In the case series from England, 70 percent of patients after DS repair had
at least mild aortic insufficiency (AI) at follow-up, including six patients
with severe AI requing AVR.
65. • Risk factors for neo-aortic root dilation were previous pulmonary arterial
banding and ASO performed in a later era
• A change in surgical technique is a likely explanation for the association
between surgery in a more recent era with neo-aortic root dilation,
possibly related to the increased size of the coronary “buttons” taken for
the translocation.
• In this current era, pulmonary arterial banding is very rare as complete
repairs are typically performed in the first week of life, thereby reducing
the frequency neo-aortic regurgitation.
66. • Coronary artery stenosis or insufficiency
• The incidence of coronary events continues to be bimodal with the
majority of events (89 percent) occurring in the first three months
following the ASO .
• These tend to be related to “kinking” or other anatomic obstructions to
coronary perfusion. Unexplained ventricular dysfunction or poor
hemodynamics should prompt early evaluation of the coronaries in the
postoperative setting.
• Risk factors for the development of coronary events include type of
coronary anatomy (presence of a single coronary orifice ) and the
occurrence of a major intraoperative event (coronary translocation
difficulty, left ventricular dysfunction, cardiac arrest, or temporary
mechanical support at the end of the intervention).
67. • Baffle-associated complications —
• Although there are limited reports of baffle-associated complications in
patients with L-TGA undergoing anatomic repair, they have been reported
frequently in adult patients undergoing D-TGA surgical repair
• Obstruction at the right atrial and superior vena caval junction is a
recognized complication of the Mustard procedure. The clinical
presentation may include chylothorax, upper extremity edema, or facial
plethora.
• Pulmonary venous obstruction is a complication more commonly
associated with the Senning procedure. Pulmonary venous congestion
may be an early manifestation. Progressive obstruction may be seen later
and may present with symptoms of reactive airway disease.
68. • Reintervention —
• Surgical reintervention is common in patients who undergo either a SR
procedure or DS operation as illustrated by the following findings from the
previously mentioned English case series :
• In the SR group (n = 45), 34 reinterventions were performed in 16 patients
including 14 right ventricular-pulmonary artery conduit changes or
ballooning.
• In the DS group (n = 68), 41 reinterventions were performed in 13 patients
including six aortic valve replacements, and surgical and catheter
reinterventions of the Senning pathway in 14 patients.
69. • FOLLOW-UP CARE —
• Longitudinal follow-up care is required in all patients with levo- or left-
transposition of the great arteries (L-TGA) by a cardiologist with expertise
in congenital heart disease.
• Clinicians need to know the potential complications following the various
surgical repairs and in unoperated patients.
• Follow-up routine care includes focused history, physical examination, and
detailed imaging study by echocardiography and/or magnetic resonance
imaging (MRI).
70. • History —:
• Episodes of syncope or palpitations that may suggest an underlying
arrhythmia or complete heart block
• Increasing exercise intolerance suggestive of declining systemic ventricular
function or increasing pulmonary artery obstruction
• Exertional chest pain may suggest coronary artery insufficiency.
• Edema of the face and upper extremities suggest superior venal caval
obstruction due to a baffle complication seen in the Senning procedure
• Dyspnea may suggest systemic atrioventricular (AV) valve regurgitation or
systemic ventricular dysfunction in the adult patient that is unoperated
71. • Physical examination —
• Vital signs, particularly the pulse, to determine any irregularity that
suggests an underlying arrhythmia
• Cardiac auscultation to detect any murmur (eg, pulmonary stenosis, aortic
or tricuspid insufficiency) or gallop (eg, failure)
• Examination for signs of cardiac failure including pulmonary congestion,
peripheral edema, and hepatomegaly
72. • Tests — Routine testing includes electrocardiography and
echocardiography.
• Electrocardiography (ECG) is performed yearly to detect and diagnose
arrhythmias. ECG is essential to look for complete heart block as there is a
2 percent annual risk for the development of complete heart block
• Holter or event recorder monitoring may be useful in patients with a
history suggestive of arrhythmia.
• Routine echocardiography is used to assess ventricular function, detect
pulmonary artery stenosis, and evaluate competency of the neo-aortic
valve. Evaluation of the systemic and pulmonary venous baffles can also
be performed with echocardiography.
• Angiography remains the preferred modality to diagnose coronary artery
occlusions in patients who undergo the arterial switch operation
73. • Cardiac magnetic resonance imaging is an excellent tool to quantify
ventricular function.
• It should be used when evaluating adults who have not undergone repair,
and can be used to accurately assess left ventricular thickness and
function in those patients who have undergone PA banding.
• This diagnostic modality is also helpful in identifying fibrosis and scar
formation.
74. • Endocarditis prophylaxis —
• Prophylactic antibiotics for endocarditis are recommended for patients
who have surgical repairs that include the use of prosthetic material (eg,
heart valve), prior episode of endocarditis, and those with high-risk lesions
for endocarditis (eg, unrepaired cyanotic heart disease or with a residual
defect such as a patch margin VSD).
75. • PREGNANCY —
• In general, women with a systemic ventricular ejection fraction that is less
than 40 percent and/or have a New York Heart functional class III and IV
should be counseled against pregnancy as the added volume load of
pregnancy is typically not well tolerated.
• In a one study of 22 women with L-TGA, 50 of the 60 pregnancies resulted
in live births including one preterm birth at 29 weeks gestation. None of
the infants had congenital heart disease.
• There were no pregnancy-related deaths but one woman developed heart
failure due to worsening systemic atrioventricular valve regurgitation.
• In addition, one woman with 12 pregnancies resulting in 10 live births
subsequently developed endocarditis and heart failure
76. Morphologic Left Ventricle Supporting
Systemic Circulation
• Early (hospital) death:
• several studies suggest that early outcomes are as good or better with
more complicated "double switch" procedures that assign the
morphologic LV to the systemic circulation.
• patients with structurally abnormal tricuspid valves, mortality was 11%
following "anatomic repair," and 33% following "physiologic repair“.
• Early mortality ranged from 0% to 14%.
78. Modes of Death
• A few patients die suddenly. this is due to sudden appearance of complete
heart block with ventricular asystole or fibrillation.
• RV dysfunction.
80. Postrepair Complete Heart Block
• In all reported series, prevalence has been 15% to 30%.
• chordal straddling or insertion on the septal crest (usually from the left-
sided tricuspid valve) increases the probability of producing complete
heart block at the time of VSD repair.
81.
82.
83. Development of Tricuspid Valve
Regurgitation
• Immediately after simple, classic repair of CCTGA with VSD, left-sided
tricuspid valve regurgitation sometimes appears.
• Operations assigning the morphologic LV to the systemic circulation result
in improved tricuspid valve function.
• Tricuspid valve regurgitation also may be associated with development of
complete heart block.
• When the RV is placed in the pulmonary circulation, tricuspid valve
function typically improves, often without specifically surgically addressing
the valve.
84. Functional Status
• Most surviving patients with CCTGA consider themselves to have normal
functional capacity.
• 78% to 83% were in New York Heart Association (NYHA) functional class I,
and the remainder in class II.
85. Ventricular Function
• When surgery involves placing the morphologic LV in the systemic
circulation, early follow-up and midterm follow-up studies demonstrate
both well-maintained LV and RV function but converse is not true.
86. "Double Switch" Procedures
Combined with Bidirectional Superior
Cavopulmonary Anastomosis
• Use of the bidirectional superior cavopulmonary anastomosis, as part of
operations for CCTGA when the morphologic LV is placed in the systemic
circulation has a number of specific advantages:
• It may benefit the small or poorly functioning RV
• It importantly reduces complexity of the atrial baffle procedure
• It eliminates complications related to the superior limb of the atrial baffle
• It reduces flow across an RV-pulmonary trunk conduit
• It likely increases conduit longevity
• This reduces myocardial ischemia time because the cavopulmonary
anastomosis can be performed during rewarming after aortic clamp
removal and myocardial reperfusion is established.
87.
88. Problems of physiologic repair
• Progressive tricuspid regurgitation
• Right ventricular dysfunction
• Atrioventricular dysfunction
• Conduit related problems
Congenitally Corrected TGA
89. Tricuspid regurgitation
• Volume load on the right ventricle
• Low incidence with naturally occurring
pulmonary stenosis
• Movement of interventricular septum
Congenitally Corrected TGA
90. Congenitally Corrected TGA
Tricuspid valve abnormality
• In IVS
Preop. 38% postop. 60%
• In VSD
Preop. 90% postop. 56%
• In VSD+PS
Preop. 36% postop. 36%
91. Causes of Tricuspid Regurgitation
• Structural alteration of tricuspid valve component
Congenitally abnormal tricuspid valve
Adherence of septal leaflet or chordae to VSD patch
Asynchronous papillary muscle contraction with RBBB
Supraventricular or ventricular arrhythmia
• Abnormal function of structurally normal valve
Dilated annulus
Distraction of papillary muscles
Right ventricular or papillary muscle dysfunction
Congenitally Corrected TGA
92. 1. Ventricle shape
Cylindric vs. crescent-shaped cavity
2. Contraction pattern
Concentric vs. bellow-like contraction
3. Pumping action
Pressure pump vs. low pressure-volume pump
4. Coronary artery supply
Two system vs. one system
5. Embryology
Primitive ventricle vs. bulbus cordis
6. Papillary muscles
Two papillary vs. small & numerous (septophylic)
Characteristics of Both Ventricles LV Vs RV
The long-term systemic workload results in progressive tricuspid regurgitation
that increases volume overload and contributes to ventricular dysfunction and
failure. Increase the vulnerability of this ventricle to ischemia, particularly
when hypertrophy is present