Cetta_edit_US_Pallet04 27/10/2009 11:08 Page 110
Congenital Heart Disease
Figure 3: Valve Fluoroscopy Performed After Mitral Valve
mechanical valve is usually performed without sedation or the need for
Replacement in an Adult with a History of Complete
invasive vascular access.
Atrioventricular Septal Defect—During Realtime Imaging,
the Leaflets Can Be Visualized in Motion, Ensuring that
the Valve Is Functioning Properly
Special mention should be made of valve reparative procedures,
including extensive remodeling of tricuspid valve tissue that occurs in
surgery for Ebstein anomaly. Rarely, dehiscence of the Ebstein repair can
This may or may not be associated with
symptoms. but can be diagnosed by clinical exam (change in the
regurgitant systolic murmur) and by the right atrial waveform (elevated
v-waves). Similar dehiscence of a valve repair has been reported after
mitral valve annuloplasty.
In addition to the above-mentioned rhythm, thrombosis, and surgical
complications noted in the post-operative period, each specific
congenital heart lesion portends its own set of potential intra- or extra-
cardiac complications. These lesions are discussed below. Regardless of
lesion, all patients should receive a post-operative electrocardiogram,
echocardiogram, and chest radiography prior to hospital discharge.
Ventricular Septal Defect
Post-operative evaluation of patients after ventricular septal defect (VSD)
repair is dependent on the type of VSD repaired, but complications are
septal defects, tetralogy of Fallot, and AV septal defects.
uncommon. All patients should have the usual radiographic and clinical
Hyperthermia has also been implicated as a risk factor for post- auscultatory follow-up. In addition, a post-operative echocardiogram is
operative JET, although the exact causative etiology behind this is usually sufficient to rule out recurrent defects in the ventricular septum.
unknown. As such, surface cooling of the patient with JET is a necessary Rarely, an undiagnosed defect may be apparent post-operatively that
Post-operative JET is usually transient.
Overall, was not found pre-operatively or during surgery. Membranous VSDs are
use of medications such as amiodarone is successful in treating 60–80% often in close proximity to the AV node and patients should be monitored
of cases of JET.
Use of catecholaminergic pressors, including for intra- and post-operative dysrhythmia.
Supracristal VSDs are
epinephrine, can exacerbate JET and should be avoided if possible. associated with aortic regurgitation and the amount of regurgitant flow
should be assessed on clinical exam and echocardiography.
Post-operative patients with congenital heart disease may eventually
require pacemaker placement. According to the American College of Atrial Septal Defect
Cardiology (ACC)/American Heart Association (AHA)/North American Similar to VSDs, complications after atrial septal defect (ASD) surgery
Society of Pacing and Electrophysiology (NASPE) 2002 guidelines, Class are uncommon and are related to the type of ASD. Echocardiography
I indications for pacemaker placement post-operatively include can be performed to rule out recurrent or residual defects of the atrial
persistent second- or third-degree AV block (for seven days or not septum. Secundum ASDs are rarely associated with transient
expected to resolve) and complete AV block with ventricular ectopy or atrial dysrhythmias, which should be monitored and treated if
dysfunction or wide QRS escape rhythm. Class IIa and IIb indications symptomatic.
After repair of a coronary sinus ASD or isolated primum
include bradycardia–tachycardia syndrome and bradycardia with ASD there is a low risk of atrial dysrhythmia.
concurrent loss of AV synchrony and impaired hemodynamics.
contrast, post-surgical AV block with return of normal conduction is not Sinus venosus ASDs are associated with anomalous pulmonary
an indication for pacemaker placement. drainage, particularly of the right-sided veins. The Warden technique has
become a popular method of repairing these defects. This technique
Considerations After Valve Replacement involves an anastomosis of the superior vena cava to the right atrial
Replacement of cardiac valves with either tissue or mechanical appendage and baffling of the anomalous veins to the left atrium.
prostheses has become routine in the modern age of cardiothoracic Pulmonary venous obstruction, superior vena cava obstruction, and
surgical care. Rarely, unexplained hemodynamic compromise in sinus node dysfunction are potential complications of this procedure.
a patient after valve replacement can signify dysfunction of the
valve prosthesis. This can occur due to thrombus formation on the valve Atrioventricular Septal Defects
despite routine post-operative anticoagulation, or immobility of one or Partial atrioventricular septal defect (AVSD), or partial atrioventricular (AV)
more of the valve leaflets.
When echocardiography shows evidence of canal, includes a primum ASD and a cleft mitral valve. Post-operatively,
an unexpectedly significant gradient or severely regurgitant valve soon these patients have a risk for transient atrial or AV nodal dysrhythmia, as
after valve replacement, valve fluoroscopy can be performed to assess well as a risk for recurrent/residual mitral valve regurgitation.
(see Figure 3). Fluoroscopic examination of a be monitored via clinical exam and echocardiography.
110 US CARDIOLOGY