경희대학교 의과대학·의학전문대학원

Operation of Acyanotic Cong

enital Heart Disease

Department of Thoracic & Cardiovascular Surge ry, Kyung Hee University Hospital

Acyanotic CHD according to the Main P

hysiologic Load

• Lesions with Volume Load

1. L-R shunt : ASD, VSD, AVSD, PDA

2. Valve regurgitation : AVSD, MR, TR, AR 3. Cardiomyopathy

• Lesions with Pressure Load

1. Obstruction of Ventricular Outlet : PS, AS, CoA 2. Obstruction of Atrioventricular valve : MS, TS

Common Lt-to-Rt Shunt Lesions

• Atrial septal defect

• Ventricular septal defect

• Patent ductus arteriosus

• Atrio-ventricular septal defect (Endoca

rdial cushion defect)

Congenital Heart Diseases Congenital Heart Diseases VSD (30  60%) VSD (30  60%) PDA(10%) PDA(10%) ASD(7%) ASD(7%) PS(7%) PS(7%) TOF(5%) TOF(5%) AS(5%) AS(5%) TGA(5%) TGA(5%) CoA(5%) CoA(5%)

Atrial Septal Defect

(ASD)

Atrial Septal Defect

• Magnitude of the left-to-rig ht shunt

: relative compliance of the RV and LV • Enlargement of RA,RV,MP A, PVM  on chest PA • RBBB pattern (rsR’ in V1) in the ECG • Heart m. : through PV, TV, widely split and fixed S2

Sinus venosus; 1,3 Secundum; 2, 5 Primum; 4

ASD

• Rarely symptomatic in infancy & childhood • In some infant ; CHF & growth failure

• CHF : rare < 10 yr, common > 40 yr

• Atrial arrhythmia increasing with age; > 40yr • Pulmonary vascular obstructive disease

; 5 ~ 10% of all ASD

Treatment

• Qp/Qs >1.5

• 3 ~ 4 yrs.

ASD Operation

우심 방

Ventricular Septal Defect (VS

D)

VSD

VSD Types

Soto Classification (popular):

1. Perimembranous type (m/c)

i) inlet extension

ii) trabecular extension

iii) outlet extension

2. Muscular type 3. Subarterial type

Kirklin Classification (classic):

1. Type I ; SA + Infundibular

2. Type II ; PM

3. Type III ; AV canal (PMIE)

4. Type IV ; Muscular (except infundibular)

Natural Courses of VSD

• Spontaneous closure

• Pulmonary hypertension

• RVOTO

• Aortic regurgitation

• Infective endocarditis

Op. Indication & Timing of

VSD

• Indication:

1. Large VSD w/ CHF, failure of thrive, PHT 2. Subarterial type

3. Aortic valve prolapse or AR 4. Secondary RVOTO or DCRV 5. LV to RA shunt

6. s/p Infective endocarditis

• Timing:

1. Large VSD w/ CHF, severe PHT ; soon after diag nosis is made (regardless of age & BWt.)

Patent Ductus Arteriosus (PD

A)

PDA : Treatment

• In preterm ; indomethacin (Pontal) ; surgical ligation

• Older infants and children

; soon after diagnosis is made

1. Catheter closure ; coil or device 2. Surgery

 Caution !!!

Recurrent laryngeal nerve injury

Atrioventricular Septal Defect

(AVSD)

Atrioventricular Septal Defect

Endocardial cushion defect (ECD)

• Anomalies at the site of atri oventricular septum and atri oventricular valves

• Down syndrome

Complete AVSD

• Symptom; early in infancy

1. Large PBF

2. Increased PAP

3. AV valve insufficiency

• Severe PVOD can occur even in infants

• Surgery; before 1 yr. (3-8 mo.)

• Special problems

- parachute MV, double orifice MV - subaortic stenosis

Partial Anomalous Pulmonary

Venous Return (PAPVR)

- Pulmonary vein 의 일부가 우심방이나 체

정맥으로 이상 연결되는 상태

- 단독으로 나타날 수도 있으나 Sinus veno

sus type 의 ASD 와 합병되어 나타날 수도

있다 .

Obstructive Lesions

• AS (LVOTO) 1. Valvular 2. Subaortic 3. Supravalvar • PS (RVOTO) 1. Valvular 2. Subvalvar(infundubular), DCRV 3. Supravalvar • CoA

Aortic Stenosis

(AS)

• Severity of AS

1. PG; in compensated asymptomatic patient < 25 mmHg 25-50 ; 50-75 ; op or intervention > 75 ; op or intervention

2. LV function ; especially in infancy 3. Hypertrophy, ischemic change, MR

4. Strain pattern on ECG, abnormal TMT 5. Symptoms ; angina, syncope, DOE

• Treatment

1. Surgical valvotomy 2. Balloon valvuloplasty 3. Valve replacement Mechanical Homograft A

utograft ; Ross operation

• Hypoplastic left heart ; Norwood op

LVOTO - Valvular AS

1 m/M

LVOTO

• Subaortic stenosis

1. A progressive lesion

2. Operation; PG > 35-40 mmHg or AR

3. Recurrent; complete resection, Konno op.

• Supravalvar AS

1. Coronary arteries, arch vessels, renal artery 2. Operation; PG > 40 mmHg

Pulmonary Stenosis

(PS)

PS - RVOTO

1. Isolated valvular PS ; 80-90% of RVOTO 2. DCRV ; anomalous muscle bundle

3. Primary infundibular PS 4. Peripheral PS

5. PS associated with systemic disease ; Noonan syndrome, tumor,

PS - Valvular

• Treatment : more than moderate PS

1. Balloon valvuloplasty : choice 2. Surgery

PG(mmHg) p(RV/LV) %

Mild < 40 < 50

Moderate 40-60 50-75

Coarctation of The Aorta

(COA)

Thank

Thank

You