A successful cardiac surgery in children requires an expert medical team - doctors, nurses, and other support staff - who are experienced in such surgeries, can promptly recognize problems and emerging side effects, and know how to react swiftly and properly if problems do arise. A cardiac surgery program will also recognize the importance of providing patients and their families with emotional and psychological support before, during and after the surgery, and will make personal and other support systems readily available to families for this purpose. We make this difficult journey easy for the patient and his relatives.
Paediatric surgeries deal with the correction of abnormalities present in the heart of new-borns, infants or children. Most of the defects are present since birth (congenital). They all come under the category of congenital heart defects. Some are present since birth but cause symptoms after a few years and some cause symptoms immediately after birth.
Major Types of Cardiac Defects in Children
Any defect in the septum or valves or position of arteries causes mixing of pure and impure blood or reduced blood supply to the body. If the defect is severe it is incompatible with life and requires immediate surgical intervention. Circulation of impure blood in the body results in bluish discoloration of the body called cyanosis. The tissues do not receive adequate amount of oxygen and hence cannot function.
The major cardiac defects include
- Atrial Septal Defect
- Ventricular Septal Defect,
- Fallot's Tetralogy
- Valvular defects
Approximately 25000-30000 children per year are affected by these defects. The paediatric surgeries deal with correction of these malformations.
Atrial Septal Defect (ASD)
ASD- Atrial Septal Defect refers to a hole in the septum that separates the right and left atrium. This results in mixing of pure and impure blood. Depending on the size of the defect, the symptoms may range from no symptoms to bluish discoloration of the body, increase pulmonary blood pressure and irregular cardiac contractions (arrhythmias). It is corrected by open heart surgery. The sternum is split in the midline. Arterial and double venous (superior vena cava and inferior vena cava) vessels are clamped. By applying cardiopulmonary bypass (heart lung machine), the aorta is clamped, and the heart is temporarily paralyzed by a solution. The right atrium is opened and the defect is sutured.
At our world class hospitals in India, minimally invasive approaches to the repair of ASD have now been developed. In most cases, the size of the incision is simply decreased with different approaches to cardiopulmonary bypass. Examples include partial or full submammary skin incision, hemisternotomy, and limited thoracotomy. The goal is to improve cosmetic results because these approaches are not associated with decreased morbidity or mortality.
In recent times, ASD have been closed by using a variety of catheter-implanted occlusion devices rather than by direct surgical closure with cardiopulmonary bypass. These devices are placed through a femoral venous approach and are deployed like an umbrella to seal the septal defect. These devices work best for centrally located secundum defects. Our cardiologist with congenital experience will continue patient care to monitor for recurrence of the shunt and to ensure that the patient has returned to normal activities and cardiac function.
Ventricular Septal Defect (VSD)
Ventricular Septal Defect - is a hole in the wall between the right and left ventricles of the heart. This abnormality usually develops before birth and is found most often in infants. A ventricular septal defect can allow newly oxygenated blood to flow from the left ventricle, where the pressures are higher, to the right ventricle, where the pressures are lower, and mix with un-oxygenated blood. The mixed blood in the right ventricle flows back or recirculates into the lungs. This means that the right and left ventricles are working harder, pumping a greater volume of blood than they normally would. Eventually, the left ventricle can work so hard that it starts to fail. It can no longer pump blood as well as it did. Blood returning to the heart from the blood vessels backs up into the lungs, causing pulmonary congestion, and further backup into the body, causing weight gain and fluid retention. If the VSD is large and surgically uncorrected, pressure can build excessively in the lungs, resulting in pulmonary hypertension. The higher the pulmonary pressure, greater the chances of blood flowing from the right ventricle to the left ventricle, backwards, causing un-oxygenated blood to be pumped to the body resulting in cyanosis (blue skin). The risk for these problems depends on the size of the hole in the septum and how well the infant's lungs function.
Small VSDs' are symptomless and closed spontaneously as the child grows. The large VSDs' cause symptoms like difficulty in breathing and feeding, poor growth and pallor. The symptoms occur due to the increase in size of the right ventricle (right ventricular hypertrophy) and increase in pressure inside the lungs (pulmonary hypertension).
Two types of surgeries are available -
Intra-Cardiac Technique - the patient is attached to an external heart-lung machine (which performs circulatory and respiratory function during surgery). It is an open heart surgery in which the patient is placed under general anaesthesia. The rib cage is cut open in the midline. The heart is directly accessed and the defect is sutured.
Trans- Catheter Technique -Surgical instruments are passed through the catheter which is inserted in the femoral artery at the groin. The catheter is slowly guided up towards the point of defect to close it. It is a successful surgery. With the separation of ventricles normal circulation resumes. The enlarged heart comes back to normal size. Pulmonary artery pressure reduces. The child's growth fastens. The prognosis is excellent.
Fallot's Tetralogy (TOF)
It is the most common congenital heart defect in children. The defect results in mixing of pure and impure blood.
It comprises a combination of four defects- right ventricular hypertrophy (increase in the size of right lower chamber), ventricular septal defect (whole in the wall between the two ventricles), abnormal position of aorta (aorta is on right side of heart instead of the left) and pulmonary stenosis (narrowing of pulmonary valve opening which prevents outflow of blood from right ventricle).
Small VSDs' are symptomless and closed spontaneously as the child grows. The large VSDs' cause symptoms like difficulty in breathing and feeding, poor growth and pallor. The symptoms occur due to the increase in size of the right ventricle (right ventricular hypertrophy) and increase in pressure inside the lungs (pulmonary hypertension).
Two major surgeries help to correct these abnormalities.
Blalock- Taussig's operation is a palliative procedure performed in smaller infants to increase blood flow to lungs and to allow the child to grow big enough to withstand the corrective surgery. A connection is made between right subclavian artery and pulmonary artery to pass more oxygenated blood to the latter. This relieves the cyanosis to a great extent.
The total corrective surgeryis performed in children within 2 years of age. VSD is closed with a patch and the narrowed pulmonary valve is opened. The outcome of surgery is favourable and most children lead a healthy life after the surgery with minimum restrictions.
Double valve repair and replacement
Valves are openings between two chambers and also between a chamber and artery which allows unidirectional flow of blood. The patency of these valves is very important for normal flow of blood. The function of mitral valve (between left atrium and left ventricle) and the aortic valve (between left ventricle and aorta) is very important. If these valves get narrowed, the amount of blood passing from left atrium to left ventricle (mitral valve) or from left ventricle to aorta (aortic valve) is drastically reduced. In this case the heart will pump blood harder to push it through the narrowed valves. But the blood will tend to go upwards back into the pulmonary vein and finally to the lungs. This will cause excess blood in the lungs leading to congestion. At the same time very less blood will come out into the aorta from the left ventricle which will result in reduced blood and oxygen supply to all the body parts.
Double valve repair and replacement procedure aims at correcting or replacing these both these damaged valves (aortic & mitral together) with new functional valves. This is done through the open heart surgery. The patient is put under general anaesthesia and connected to the heart lung machine. This machine takes over the pumping, circulatory, and respiratory functions of the heart and lung till the surgical procedure is going on. The valves are accessed by cutting open the rib cage and accessing the heart directly. The old valves are sliced from their attachments and new valves are put in their place. The new valves may be obtained from a cadaveric donor, or an animal (pig) or it may be made of a nonreactive inert material. The patient needs to be given anticoagulants or immunosuppressive to clotting of blood or rejection of organ. The prognosis of this surgery is good. It is many a time a life-saving and life extending surgery.
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