Palliative Operation

Seoul National University Hospital

Department of Thoracic & Cardiovascular Surgery

Aims of Palliative Operations

• Purposes Operations have been designed to alter the hemodynamic physiolog

y, to make the cardiac malformation more tolerable

so as to allow improvement in the patient’s condition, to allow conti

nued growth, and to by time.

• Three principal objectives

Operations to increase pulmonary blood flow

Operations to decrease pulmonary blood flow

Operations to increase pulmonary-systemic mixing

Palliative Procedures in CHD

1 Systemic artery-pulmonary artery shunt Blalock-Taussing in 1945

Potts in 1946

Waterston in 1962

2 Systemic vein-pulmonary artery shunt Glenn in 1958

Fontan & Baudet in 1968

3 Pulmonary artery banding Muller & Dammann in 1952

Palliative Surgery

• Systemic – pulmonary artery shunt Blalock-Taussig shunt Unifocalization and shunt Cavopulmonary shunt (BCPS)

• RVOT reconstruction Valvotomy Patch widening Valved conduit

• Pulmonary artery banding• Atrial septectomy

Systemic–Pulmonary Artery Shunt

Systemic – Pulmonary artery shunt is indicated

due to age, size, anatomy or other conditions

when;

1. Complex anomaly with severe cyanosis,

irritability, hypoxic episode

2. Critically ill neonates or infants due to decreased

pulmonary blood flow

3. Facilitating growth of hypoplastic pulmonary artery

Disadvantages of Classic B-T shunts

1. Longer operative dissection time

2. Phrenic nerve injury

3. Technical difficulties during takedown

4. Possible arm ischemia

Advantages of Sternotomy for Shunt

1) Less demanding for shunt construction with

greater control of vessels without the risk of

lung compression

2) Able to institute cardiopulmonary bypass

3) Complication rate is lower with even flow

distribution

4) Single scar

RMBT Shunt (Midline Approach)

BT Shunt

RMBT Shunt (Midline Approach)1 m. TGA+VSD+PS

BT Shunt

Bidirectional Cavo-pulmonary Connection

BCPC

Bidirectional Cavo-pulmonary Connection

BCPC

Bidirectional Cavo-pulmonary Connection 5m, SV+ PS

BCPC

Thromboembolic Event after Shunt

• Incidence; 3~5%• Etiology 1. Hematologic Inherited abnormality of coagulation factors Protein S, C, factor V Leiden, antithrombin III

2. Mechanical 3. Pulmonary hypertension 4. Infections

• Treatment Warfarin (reducing the Vk dependent proteins) Low-molecular weight heparin Newborns are low in Vk dependent protein( 50% of adult level , reach adult level at 6 months)

Control of congestive heart failure Complex or multiple VSD (with/without CoA) Single ventricle, Tricuspid atresia without PS Protection of pulmonary vascular bed Single ventricle – Fontan operation Preparation of LV for arterial switch operation TGA with IVS / restrictive VSD

Pulmonary Artery Banding

Pulmonary artery banding is indicated to decrease

pulmonary blood flow and prevent pulmonary vascular

obstructive disease when ;

Pulmonary Artery Banding

Aims of banding To decrease the volume of the left to right shunt and thus the work of left ventricle, and minimize pulmonary vascular engorgement and protect the pulmonary vascular disease. ( Sick infants less than 6 months of age, or more, with intractable congestive failure and failure of growth, or with those complex lesions unsuitable for primary repair in infancy )

Pulmonary Artery Banding

Consequence1 Mortality rate

2 Imperfect banding

3 Obliteration of pericardial space

4 Pulmonary artery distortion & maldistribution

5 Thickening of pulmonary valve

6 Subaortic stenosis

Pulmonary Artery Banding• Diagnosis (ILI), Dextrocardia

ECD, IVC interruption ,

1 month old

Pulmonary Artery Banding F/3m, RV-type SV

PA Banding

Pulmonary Artery Banding

Disadvantages 1. Failure to control adequate pulmonary

blood flow

2. Distortion of pulmonary valve and artery

3. Progression of cardiac hypertrophy and

subaortic obstruction

4. Changes of cardiac diastolic & systolic

function

Mixing Procedures

• Operations to increase venous mixing

of pulmonary-systemic venous returns

1. Rashkind septostomy by balloon catheter

2. Park blade atrial septostomy

3. Blalock-Hanlon closed atrial septectomy

4. Palliative atrial switch

Atrial Septectomy

For the increase of effective pulmonary blood flow

and systemic oxygen saturation

Indications of atrial septectomy : TGA Tricuspid atresia Pulmonary atresia with intact vetricular septum MV & LV hypoplasia Decreasing tendency of indication due to early total correction or intervention