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cardiac surgery.


  • 1.Classification: Acyanotic congenital heart disease. Cyanotic congenital heart disease. Patients become cyanosed very soon after birth

2. CYANOTIC CONGENTIAL HEART DISEASESA. Fallots Tetralogy: 3. Fallots Tetralogy: Ventriculoseptal defect results in equal pressure within bothventricles. As a result of the pulmonary stenosis, more blood isdischarge into the aorta and cyanosis results. Lungs are only partially perfused and total oxygen is poor. Anomaly results in right to left interventricular shunt due toright outflow tract obstruction and high right ventricularpressure. 4. COMPLICATIONSLose of consciousness due to cerebral anorexiaPolycythemiaAbout 1/3 of patients are cyanotic at birth, these patients oftendo not survive infancy unless operation is performed quickly.Threat to life in the 1st year is cerebral infarctionBrain abscess 5. SYMPTOMS:Asymptomatic at birth. soon after, infants become cyanosis.Systemic cyanosisUndersize childClubbing of finger and toesExertional dyspneoa and tiredness.After walking a short distance, body spontaneous desire to squat:increase systemic vascular resistance & blood is diverted into thepulmonary circulation with increase oxygenation. 6. INVESTIGATIONHeart of normal sizeA systolic murmur present at 3rd & 4th intercostal space.X-ray: Boot-shaped with poorly developed lung vasculature.ECGCardiac catheterizationSelective angiocardiography 7. Fallots TetralogyAnastomotic palliative treatment:1.Blalocks anastomosis: performed on child of a few weeks to 5 yearsAnastomosis of pulmonary artery to the left subclavian artery. Incision: A left postero-lateral thoracotomy through the 4th intercostal space.2.Waterstons anastomosisAnastomosis of ascending aorta andright pulmonary artery. Incision: A right antero-lateral thoracotomy through the 4th intercostalspace.3.Potts AnastomosisAnastomosis of ascending aorta to left pulmonary artery. 8. Fallots TetralogyTotal correction:Technique: performed btw 5 and 10 years of child ageOperation carried out through median sternotomy with help of extracorporeal circulation High vertical ventriculotomy perform which stop near the pulmonary annulus through this incision ventricular septal defect closed with dacron patch Pulmonary vulvular and infundibular obstruction is also widenedwith patch graft of dacron Continue 9. Fallots TetralogyVentriculotomy closed with dacron patch, extracorporeal circulation is stoppedMeasured intracardiac pressure to confirm the right ventricular systolic pressure reduced to less than 60 to 70% of that of left ventricle. This operation risk is about 10% for small children, only 2 to 5% inolder children 10. After correction there may be alveolar edema.It may be necessary to prolong artificial ventilation with theuse of PEEP.And to wean the patient off the ventilator with the use of CPAP.Breathing exercise with emphasis on inspiration areparticularly important.Fine shaking and percussion to be helpful in the resolution ofthe peripheral lung involvement.Discharge is btw 2 & 3 weeks, total correction is prefferedbefore school age. 11. The Condition was first described by Morgagny.Aorta arises from Rt ventricle, pulmonary artery arises from Lt ventricle.The two circulations, pulmonary and systolic,instead of being in seriesare in parallel. 12. The pulmonary and systemic circulations are separated.Venous blood circulate round the body while oxygenated bloodcirculate round the lungs.For the child be survive there must be a communication btwtwo circulation.Possible communications are persistent ductusarteriosus, arterial septal defect or ventricular septal defect. 13. SYMPTOMS:Deeply Cyanotic at birth(80%)SyncopeDyspneoa on exertionCardiac failureClubbing & Polycythemia 14. TRANSPOSITION OF GREAT VESSELSSurgical procedure; palliative treatment:1.Procedure is balloon septostomy ruptured(Rashkind and Miller,1966) to create an atrial shunt.2. Atrial septal is excised (Blalock and Hanlon,1950)The Rt atrium and pulmonary vein are parallely incised.A portion of the atrial septum is excised and two incisions are nowanastomosed. 15. Total anatomical correction:Disconnecting the pulmonary artery from left ventricle andaorta from right ventricle Coronary artery must be implanted onto the pulmonary artery, acting as major vessel from Lt ventricle 16. The pulmonary venous drainage has become disconnectedfrom the left atriumAnd drains into the systemic venous circulation at some point oInferior vena cava, oSuperior vena cava, oCoronary sinus, oRight atriumThere is mixing of the pulmonary circulation though a patentforamen ovale. 17. Occurs in the reversal of the left-to-right shunt.Some of conditions are: oAtrial and ventricular septal defect, oPatent ductus arteriosus.But the Rt ventricle hypertrophies and the pressure in thepulmonary artery increases as a result of the increased flow.Increased pulmonary HT leads to equalization of pressureeither side of shunt, but, at some point, the right-sided pressurewill exceed and desaturated blood enters the Lt side of thecirculation 18. Symptoms: oCyanosis oDyspneoaIt is irreversible diseasesCloser of the shunt is contraindicated if pulmonary HT isirreversible bcoz the Rt-to-Lt shunt now serves to decompressthe pulmonary circulation 19. Physiotherapy Treatment :Pre-operative Treatment :Infants with cardiac problem have pulmonary hypertensionassociated with excessive secretion leading to repeated chestinfection.So chest physiotherapy important that the lung field are clear aspossible prior to the surgery.PercussionShaking and vibrationsPostural drainage 20. Post-operative Treatment :Carefully watch the patients vital signs at all times.As soon as the child is stable, usually use the side lyingposition, with care not to disrupt line, wires or infusions.In some unit treatment will be on the day of operation, inothers, day after.Depends on the type of operation the patient may or maynot be ventilated.Patients should be assessed and physiotherapy given asnecessary. 21. Percussion and vibrations should be avoided if post operativebleeding is persistent.Manual hyperinflation may enhance secretion clearance andnegligible effect on oxygen saturation (Hussey et al,1996).Patients have small amount of secretions easily removed bysuction alone.Early mobilization is important to stimulate deep breathingand coughing.Nasopharyngeal suction may be used in infants and children. 22. Specific consideration: Pulmonary HT crises.Elevation of pulmonary artery pressure which restricts flow through thelungs. Air way suction and chest physiotherapy is indicated, inspired oxygen should be increased & treatment time kept to a minimum. Delayed sternal closureOccasionally post operative closer of sternum is impended bypulmonary, myocardial or chest wall edema. If child is stable and if the sternum edges feels, the child can turned into a side lying position Manual hyperinflation is well tolerated and gentle posterior and posterolateral vibrations can be applied. 23. Phrenic nerve damage oItis a well-documented complication of pediatric cardiac surgery(Main,1995). oInability to wean from mechanical ventilation. oParadoxical movement is present.Patient is positioned head up to relive the pressure from theabdominal viscera 24. References :1.) Textbook of surgery by, S.Das , 5th Edition.2.) Bailey & LovesShort practice of surgery , 22nd Edition.3.) DavidsonsPrinciples & practice of medicine , 20th Edition.4.) Cashs Textbook ofChest , Heart and Vascular Disorders for Physiotherapists , 4th Edition.5.) physiotherapy for respiratory and cardiac problems ( pryor and prasad) third edition6.)Tidys Physiotherapy, Twelfth edition 25. THANK YOU