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[Reoperation in congenital heart defects after primary surgery in the neonatal period and infancy]
B Hucín1, M Kostelka, T Tláskal
1Kardiocentrum, Fakultní nemocnice v Motole, Praha.
Insights
Reoperations for congenital heart defects are complex. Staged procedures are the main reason, but residual defects and complications can be reduced by improving primary surgeries.
Area of Science:
- Pediatric Cardiac Surgery
- Congenital Heart Defects
- Reconstructive Cardiac Procedures
Context:
- Reoperations in pediatric cardiac surgery for congenital heart defects (CHDs) present significant technical and prognostic challenges.
- These complex reconstructive procedures carry a high operative risk and a broad spectrum of potential hazards.
Purpose:
- To analyze the reasons, outcomes, and complications of reoperations in children undergoing surgery for congenital heart defects.
- To identify factors contributing to reoperations and suggest preventive measures for primary surgical interventions.
Summary:
- A study of 2250 children operated on for CHDs between 1969-1996 found 524 (27%) required 672 reoperations.
- The primary drivers for reoperation were staged procedures for complex defects (477 children), residual defects post-primary surgery (123 infants), and extracardiac complications (21 children).
- Common causes included scar tissue, compromised myocardial growth from palliative procedures, non-growing synthetic materials, technical errors, iatrogenic injuries, and misdiagnoses.
Impact:
- Staged procedures remain the leading cause of reoperations for CHDs, difficult to mitigate due to the prevalence of complex cases.
- Improving primary surgical techniques and addressing residual defects can significantly reduce the need for subsequent reoperations and associated complications.
Background:
Reoperations in cardiac surgery of congenital heart defects represent not only the difficult technical problem but also a prognostic one. They are demanding reconstructive procedures with broad spectrum of hazards and are definitely cumulating the operative risk.
Methods And Results:
At the Pediatric Kardiocentrum, University Hospital Motol, Prague, there were 2250 children operated on for congenital heart defects in the first year of life and followed up during 1969-1996. There were 1701 primary corrections (75%) and 549 palliative procedures (25%). After operation 1912 survivors (85%) were followed-up to 25 years. Later on 524 children (27%) were reoperated with 672 procedures. There were three main reasons for reoperation: 1. Staged procedures of complex heart defects in 477 children. 2. One hundred seventy four reoperations for residual defects were performed after primary procedure in 123 infants. There were 11 corrections of residual intracardiac shunts and 120 repairs of residual stenoses. There were 58 repairs of recoarctation, 40 pulmonary artery reconstructions after arterial shunts and 43 reoperations on valves for restenosis or worsened regurgitation. 3. Other 21 extracardiac complications of primary operation were solved by pacemaker implantation (8), plication of paralysed diaphragm (6), chylothorax (3) and other (4). The causes of reoperations represent 7 main categories: 1. Solid scars, adhesions and fibrous bands cause stenoses. 2. Palliative procedures influence positively the hemodynamics, but compromise the development and growth of myocardial wall. 3. Synthetic materials are nor growing but produce obstructions. 5. Incomplete primary correction and technical errors. 6. Iatrogenic injury of the phrenic nerve or the bundle of His. 7. False diagnosis. The hazards of reoperations are: 1. High risk of resternotomy with catastrophic bleeding. 2. Difficult cannulation for heart-lung bypass, and problematic induction of cardioplegia. 3. Difficult dissection of all structures with the high risk of bleeding on the site of aorta, lung hilum or coronary arteries. 4. Difficult left heart decompression and defibrillation of the heart. 5. Paralysis of the diaphragm.
Conclusions:
Staged procedures are the major source of reoperations. Their volume does not change much and it is difficult to influence it because still a large number of complex heart defects are operated every year. On the contrary the residual or recurrent defects as well as a number of further complications can be influenced by preventive measures during primary operation.