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Cardiac Surgery in Early Infancy J Postgrad Med J: first published as 10.1136/pgmj.48.562.478 on 1 August 1972. Downloaded from Postgraduate Medical Journal (August 1972) 48, 478-485. Cardiac surgery in early infancy J. STARK M.D. Hospital for Sick Children, Great Ormond Street, London, W.C. 1 IMPORTANT advances have been made in the diagnosis and treatment of congenital heart disease (CHD) in early infancy. Accurate diagnosis is now possible in the first days or even hours of life. Operation is also 3530- possible at this early age and very often it provides 0 the only chance for survival. The risk of conservative E .4In15 treatment often exceeds the risk of the operation. O- An aggressive approach to the diagnosis and treat- II II II ment of CHD is dictated by statistics. The estimated z a 10 5 incidence of CHD is 6-8/1000 live births. About 500o 963 99 6 of the children born with CHD die before their first 3 1 1 5 1 16 birthday unless effectively treated. The achievements in the treatment of CHD in infancy are the result of 1963~51964 1965 1966 1967 1968 1969 1970 1971 the combined efforts of paediatricians, cardiologists, FIG. 1. Open-heart surgery under I year of age at the copyright. surgeons, anaesthetists and nurses. Many other Great Ormond Street Thoracic Unit, February 1963 to specialists and technical staff contribute to the September 1971 (115 patients). Open columns, survived; diagnosis and treatment. closed columns, died. The experience of the Thoracic Unit, Hospital for Sick Children at Great Ormond Street, forms the Diagnosis basis of this report (unless otherwise stated). Table 1 Clinical diagnosis of congenital heart anomalies is shows the overall experience with surgical procedures not always easy. This is because several anomalies in infancy and it also indicates the proportion of may be present in one patient and the interpretation patients requiring surgery early in life (under the age of physical signs may be difficult. However, cardiac of 12 months). Although palliative procedures were catheterization and angiocardiography can differen- http://pmj.bmj.com/ for a long time preferred in small babies, the total tiate various defects with great accuracy. Only pre- number of corrective procedures under the age of cise diagnosis can prevent serious errors in indica- 1 year increases progressively. Figure 1 shows the tions and operative treatment. No infant should be overall experience with by-pass surgery under the considered too ill for cardiac catheterization and age of 1 year. It demonstrates the improving chances angiocardiography. We feel that there is no longer a of infants submitted to open-heart surgery in recent place for exploratory thoracotomies to compensate years. for inadequate investigation. Furthermore, no infant on October 5, 2021 by guest. Protected should be considered too ill for an operation, because TABLE 1. Surgical experience 1946 to August 1971 very often this is the only chance for survival to a Diagnosis Total Under 1 year desperately ill baby. As any delay in investigation or operation may provefatal, teams of investigators and Patent ductus arteriosus 1037 259 (25%) be a 24-hr Systemic-pulmonary shunts 739 283 (38%) surgeons should available on basis. To Coarctation of aorta 445 238 (53%) wait until the child demonstrates his will to live is Pulmonary artery constriction 292 244 (83%) no longer an acceptable concept. This, we feel, Transposition of the great arteries merely gives an excuse for not providing adequate Atrial septostomy 217 164 (75%) and facilities. Mustard operation 177 36 (21%) diagnostic surgical Pulmonary stenosis 122 32 (26%) Total anomalous pulmonary Indications venous drainage 78 57 (73%) Cardiac operations in infancy are performed for Vascular rings 47 40 (85%) two main reasons-severe hypoxemia and/or severe Total 3154 1353 (43%) congestive heart failure. The most severe lesions Postgrad Med J: first published as 10.1136/pgmj.48.562.478 on 1 August 1972. Downloaded from Cardiac surgery in early infancy 479 present in the first month of life. Because most of the considered (loss from gastric aspiration, excessive deaths occur very early, operation should be sweating or gains from flushing the intravenous or attempted as soon as possible after the diagnosis has intra-arterial catheters). The accuracy of fluid intake been made. It may be a palliative procedure for is checked regularly by estimating the haematocrit lesions where correction in early infancy carries too and both plasma and urine osmolality. An inadequate high a risk. Corrective operation may be as simple fluid intake can cause thickening of bronchial secre- as ligation of patent ductus arteriosus or it may be tions with subsequent atelectasis, and increased an open-heart procedure requiring the heart-lung blood viscosity (high haematocrit) presents extra apparatus (total anomalous pulmonary venous work for the circulatory system. Excessive fluid intake drainage, transposition of the great arteries, etc.). may cause fatal pulmonary oedema. Oral feeding is The decision between palliative and corrective pro- probably the best prevention of water and electrolyte cedures is not always an easy one. All factors should imbalance. It can often be started 8-12 hr after the be carefully considered. These factors include opera- operation. tive risk of correction early in infancy compared with the combined risk of palliative procedures and cor- (b) Acid-base balance rection a few years later; chances of achieving a com- plete and lasting repair on a very small heart against Both respiratory and metabolic disturbances of progressive and possibly permanent damage caused acid-base balance are common. Cyanotic babies by an uncorrected lesion (pulmonary vascular disease may present with severe metabolic acidosis, while in ventricular septal defect or hemiplegia in cyanotic respiratory acidosis is seen mainly in infants with a heart lesions). Other factors include the emotional large left-to-right shunt. Metabolic alkalosis, which strain which a staged operation presents for the often follows open-heart procedures in small infants, parents, and last but not least, the experience and is not yet fully understood. Respiratory alkalosis can ability of the team of surgeons, physicians, anaes- develop in patients on intermittent positive pressure thetists and nurses is a factor. breathing if the Pco2 is not regularly checked. Early very important diagnosis is the first step towards effective treatment. Samples of arterial blood for blood gas analysis (pH, copyright. Operation Pco,, standard bicarbonate) can be obtained by direct Some of the more frequently used procedures will puncture of the peripheral arteries, butan indwelling be described later. The success of the operation does arterial catheter gives a better opportunity to obtain not depend only on surgical skills, but supervision frequent samples and arterial pressure can be con- of acid-base balance, monitoring of blood pressure, tinuously monitored at the same time. temperature and fluid output and intake often deter- Metabolic acidosis is treated with sodium bicarb- mine the final outcome. onate or THAM, but unless adequate peripheral perfusion is established by surgical intervention, Postoperative care these measures are often of only temporary value' http://pmj.bmj.com/ In our view, postoperative care is an integral part Respiratory acidosis is treated with intermittent of the treatment of CHD. It is as important as a positive pressure ventilation by a nasotracheal tube precise pre-operative diagnosis and as the operation or tracheostomy. Volume-controlled respirators are itself. The importance of good postoperative care preferred. should never be underestimated. Details cannot be discussed in this paper: the following remarks are (c) Postoperative heart failure only intended to outline the programme and to point out some of the more Heart failure may persist from before the opera- on October 5, 2021 by guest. Protected important features. tion or it may develop afterwards. Digoxin is given in the usual dose, that is 0.08 mg/kg body weight in (a) Fluid balance a 2-4 kg baby, reducing the dose to 0.04 mg/kg bod) The right amount of fluid to be given in the post- weight at 10-15 kg. If an immediate inotropic effect operative period is still being discussed. Because of is required, catecholamines (isoprenaline or adren- the 'physiological' postoperative retention, both aline) are used in a slow intravenous drip. The small- water and sodium should be restricted for the first est effective dose is used to ensure an inotropic and few days after the operation. At present we give 5/0 peripheral vasodilating effect. We do not exceed the glucose solution with no added sodium for the first dose of 1 ,ug/kg body weight/min. Diuretics (frus- 48 hr. The volume of fluids is usually restricted to emide, chlorothiazide, spironolactone), adequate about half of the patient's normal daily requirement sedation (morphine 0'02 mg/kg body weight), de- (calculated on the basis of age and weight). The compression of the stomach with a nasogastric tube, calculated amount is very strictly adhered to and all oxygen and antibiotics are also important in the additional sources of intake or output should be treatment of postoperative heart failure. Postgrad Med J: first published as 10.1136/pgmj.48.562.478 on 1 August 1972. Downloaded from 480 J. Stark (d) Heat control failure despite full medical treatment. This happens Infants with congenital heart lesions tolerate post- not infrequently. From a total of 1037 children operative heat loss poorly. Every effort should be operated for ductus arteriosus in the Thoracic Unit, made to maintain a steady environmental tempera- 259 (25%) were under the age of 1 year (Table 1). ture. Frequent handling of the patient, together with the number of drains, intravenous and monitoring Operation lines, and connections to the ventilator make the use The ductus can be ligated or divided.
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