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Congenital Heart Disease
Essentials in the Post-operative Evaluation of Congenital Heart Disease
Jonathan N Johnson, MD
1
and Frank Cetta, MD
1,2
1. Department of Pediatrics, Division of Pediatric Cardiology; 2. Department of Medicine, Division of Cardiovascular Diseases, Mayo Clinic, Rochester
Abstract
Recent decades have seen significant advances in care for patients with congenital heart disease. Patient survival has improved dramatically,
widening the number and scope of patients treated by congenital cardiologists. Knowledge of appropriate care and follow-up of the post-
operative patient with congenital heart disease is essential to ensure continued advances in survival and quality of life. Potential post-operative
complications can be classified as being associated with intraoperative management (surgical technique, cardiopulmonary bypass, and
perfusion), anatomical substrate, or intensive care management. Surgical technique complications can include pleural or pericardial effusions,
chylothorax, and diaphragmatic or vocal cord paralysis. Post-operative cyanosis can occur, which can be due to inadequate oxygenation,
residual shunts, or fistulous connections. Arrhythmias, stroke, pulmonary emboli, and kidney or liver failure can occur post-cardiopulmonary
bypass or in the post-operative period. In addition, pain control and wound concerns can affect management considerably. This article
summarizes lesion-specific complications and concerns for individual patient anatomical substrate.
Keywords
Congenital heart disease, post-operative, complications, arrhythmias, effusion
Disclosure: The authors have no conflicts of interest to declare.
Received: August 10, 2009 Accepted: September 22, 2009
Correspondence: Frank Cetta, MD, Mayo Clinic, Gonda 6, 200 First Street SW, Rochester, MN 55905. E: cetta.frank@mayo.edu
The last 60 years have seen significant changes in the care of congenital a systemic right ventricle in congenitally corrected transposition and an
heart disease for both pediatric and adult patients. Increasing patient unrepaired anomalous coronary artery in tetralogy of Fallot. Sequelae
survival rates have widened the number and scope of potential meanwhile consist of incurred conditions that arise as a result of the
patients seen by congenital cardiologists.
1
These patients often undergo operation and that are considered necessary consequences of
multiple surgeries, particularly since few lesions are truly ‘repaired.’ The the operation. They are specifically ‘intrinsic to the operative design.’
3
majority of patients will have residua or sequelae of surgery, requiring Examples include ventricular tachyarrhythmias after ventriculotomy and
long-term follow-up or further operations. A thorough understanding of pulmonary regurgitation after tetralogy repair.
the post-operative patient with congenital heart disease is essential for
all physicians who are involved in any aspect of their care. Complications in the Immediate
Post-operative Period Related to
Residua versus Sequelae Intraoperative Management
Surgeries for congenital heart disease are typically reparative, palliative, Any intrathoracic procedure portends a risk for pneumothorax or
or revisionary. Full knowledge of the scope and variety of presentation hemothorax. The risks of clinical compromise from pneumothorax are
of lesions is necessary for clinicians caring for post-operative patients. largely negligible with routine chest tube placement. Continued air leak
In general, potential post-operative complications can be classified as from chest or mediastinal tubes should raise the possibility of a
being associated with intraoperative management (surgical technique, bronchial air leak.
4
Persistent blood drainage from chest tubes may
cardiopulmonary bypass, and perfusion), anatomical substrate, or indicate a continued bleeding source, and chest exploration may be
intensive care management.
2
performed to identify the source. Fresh frozen plasma infusions can
be used to replenish coagulation factors. Platelet infusions can be used
Perloff has divided post-operative conditions into categories: ‘residua’ to assist in obtaining hemostasis.
and ‘sequelae.’ Residua refers to conditions that are ‘left-over,’ i.e. that
are obligatory to or consequences of the pre-operative diagnosis and Pleural effusions occur commonly post-operatively, especially in the first
state. They are separate from the operative design and are not the result days following surgery as fluid shifts occur after cardiopulmonary
of surgery having fallen short of its objective.
3
Examples of this include bypass. These effusions should be treated with aggressive diuresis and
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