Timing of surgery/catheter intervention in common congenital cardiac defects

A large load of children with congenital heart disease (CHD) exists in our country. Fortunately facilities for treatment of almost all types of defects are available, although in few centres only. Many children are however, referred late for correction making them either high risk for surgery or inoperable due to development of irreversible pulmonary vascular obstructive disease. Therefore, it is important to recognise the ideal time of intervention in different types of CHD. A child with large atrial septal defect should have its closure by 3 to 4 years of age; on the other hand, a large ventricular septal defect (VSD) producing congestive heart failure needs very early surgery. Infants with small VSD may be medically managed as chances of spontaneous closure are high. Ligation of patent ductus arteriosus should be done at about one year of age if there is no pulmonary arterial hypertension or congestive heart failure. Similarly, coarctation should be dealt with either balloon dilatation or surgery at about one year of age provided the left ventricular function is normal and blood pressure in upper limb is well under control. For tetralogy of Fallot, correction is best done at about 9 months to one year of age. In case the child is symptomatic early, either a palliative shunt is done or total correction is performed if anatomy is suitable. In admixture lesions like transposition of great arteries (TGA), persistent truncus arteriosus or total anomalous pulmonary venous drainage, a very early intervention is needed so as to avoid development of severe hypoxia and early pulmonary vascular obstructive changes. Arterial switch operation is best performed in first two to three weeks of life for TGA with intact ventricular septum cases. Knowledge of natural history of the CHD is essential to plan for optimal timing of surgery or catheter intervention.