Surgical Indication Atrial Septal Defect

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Surgical Indication Atrial Septal Defect
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Anatomical Indications

• Uncomplicated ASD
• PAPVC (partial anomalous pulmonary venous
  connection, PAPVR) with evidence of RV volume
  overload

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Hemodynamic Indications

• Pulmonary-systemic blood flow ratio (Qp/Qs) ?2
• uncomplicated anomaly Qp/Qs?1.5
• Exception Scimitar syndrome (PAPVR) with severe
  hypoplasia of the right lung and a Qp/Qslt2
  (However, surgery may be needed because of
  complications of bronchopulmonary sequestration)

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PAPVC

• Isolated PAPVC of a part of one lung without an
  ASD is not an indication when the Qp/Qslt1.8
• Isolated PAPVC of a whole lung is an indication
  (should the normal lung be importantly
  compromised potentially fatal anoxia occurs)

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Age

• Age lt 5y/o (12y/o can be considered for
  deleterious effects of long- termed RV volume
  overload), but diagnosis was often made later in
  life
• Age is not an contraindication (very young or
  very old)

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Pulmonary vascular resistance

• Pulmonary vascular resistance812 Um2 at rest
  and cannot decrease to less than 7 under
  pulmonary vasodilator were surgical
  contraindication (Qp/Qslt1.5 with elevated
  pulmonary artery pressure is often, sometimes
  present with Qp/Qs2)

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Associated TR, MR

• Associated TR and/or MR (present particularly in
  older patients) is not a contraindication to
  operation
• Grading of MR angiography is difficult (ASD
  present and major runoff from left to right
  antrium) and regurgitation became important when
  ASD closed
• Moderate MR is usually an indication for MVR

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Summary

• Pulmonary-systemic blood flow ratio (Qp/Qs) ?2
• Pulmonary vascular resistance812 Um2 at rest
  and cannot decrease to less than 7 under
  pulmonary vasodilator were surgical
  contraindication

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Ventricular Septal Defect
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• A schematic presentation of the three main
  anatomic components of the interventricular
  septum as seen from the morphologic right
  ventricle (A) and the morphologic left ventricle
  (B). Component 1 septum of the atrioventricular
  canal Component 2 septum of the muscular
  septum and Component 3 parietal band or distal
  conal septum.

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• Planes of Doppler interrogation for different
  ventricular septal defects as seen in parasternal
  short axis.

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Surgical Indications Symptom

• Approximately 30 of infants with severe symptoms
  form VSDs requires operation within the first
  year of life because of intractable congestive
  heart failure or, more commonly, failure to
  thrive
• Symptomatic Qp/Qsgt1.5, pulmonary artery systolic
  pressure gt 50mmHg, increased LV and LA size, or
  LV dysfunction

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• The majority of membranous and muscular VSDs tend
  to close spontaneously.
• Surgical closure early in life is indicated only
  if the infant has failed aggressive medical
  management with digitalis and diuretics

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Asymptomatic infant with persistent VSD

• Cardiac catheterization should be performed at
  the end of the first year of life. If pulmonary
  artery pressure gt ½ systemic pressure, closure
  should be performed.

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Hemodynamic Indication

• Qp/Qs?1.5
• Pulmonary artery systolic pressure gt 50mmHg

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Pulmonary Vascular Resistance

• If pulmonary arteriolar resistance is less than 7
  Wood units, closure can be safely undertaken
• lt1y/o, with VSD, pulmonary-to-systemic vascular
  resistance gt0.7 are still considered surgical
  candidates
• because the likehood that elevated pulmonary
  vascular resistance reflects irreversible
  pulmonary vascular change within the first year
  of life is extremely small.

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Aortic Incompetence

• VSD with first showed the development of the
  murmur of aortic incompetence (AI), repair of VSD
  should be promptly accomplished while the AI
  still mild
• Cusp prolapse was showed in association with any
  juxtaaortic VSD, early repair is also indicated
• Juxtaarterial VSDs and right ventricular outflow
  juxtaaortic VSDs of significant size, even
  without cusp prolapse should be closed before
  5y/o, to prevent cusp prolapse

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Aortic Incompetence

• When moderate or severe AI and cusp prolapse were
  noted, operation should be undertaken promptly.
  It should be done before 10y/o
• Reconstruction of the valve is usually possible
  when OP is done during the first decade of life
• UAB the average age of the patients requiring
  replacement was 19.5 years, compared with 12.1
  years for the remainder of the group

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Aortic Incompetence

• When no cusp prolpase and severe AI with minimal
  enlargement of the sinuses is present, a bicuspid
  valve is probably present, and valve replacement
  may be required. (It means AR was not induced by
  VSD) VSD repair should be postponed until
  significant symptoms develop or LV enlargement
  itself indicates the need of for operation
• When the operation is delayed until adult life,
  aortic valve replacement is usually required.

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Summary (1)

• Surgical indications
• Qp/Qs?1.5
• Pulmonary artery systolic pressure gt 50mmHg
• pulmonary arteriolar resistance lt 7 Wood units
• VSD related AI (RCC prolapse, NCC prolapse)

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Summary (2)

• Membranous and muscular type VSD may close
  spontaneously

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References

• Kirlin Cardiac Surgery
• Zipes Braunwalds Heart Diseae A Textbook of
  Cardiovascular Medicine
• Park Pediatric Cardiology for Practitioners
• Cardiac surgery of the neonate and infant