Cardiology
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Pediatric heart surgery
Heart surgery in children is done to repair heart defects a child is born with (congenital heart defects) and heart diseases a child gets after birth that need surgery. The surgery is needed for the child’s well-being.
There are many kinds of heart defects. Some are minor, and others are more serious. Defects can occur inside the heart or in the large blood vessels outside the heart. Some heart defects may need surgery right after the baby is born. For others, your child may be able to safely wait for months or years to have surgery.
One surgery may be enough to repair the heart defect, but sometimes a series of procedures is needed. Three different techniques for fixing congenital defects of the heart in children are described below.
Open-heart surgery is when the surgeon uses a heart-lung bypass machine.
An incision is made through the breastbone (sternum) while the child is under general anesthesia (the child is unconscious and does not feel pain).
Tubes are used to re-route the blood through a special pump called a heart-lung bypass machine. This machine adds oxygen to the blood and keeps the blood warm and moving through the rest of the body while the surgeon is repairing the heart.
Using the machine allows the heart to be stopped. Stopping the heart makes it possible to repair the heart muscle itself, the heart valves, or the blood vessels outside the heart. After the repair is done, the machine is removed, and the heart is started again. The breastbone and the skin incision are closed up.
For some heart defect repairs, the incision is made on the side of the chest, between the ribs. This is called a thoracotomy. It is sometimes called closed-heart surgery. This surgery is done using special instruments and a camera.
Another way to fix defects in the heart is to insert a few small tubes into an artery in the leg and pass them up to the heart. Only some heart defects can be repaired this way.
For more information about specific repairs, see: Congenital heart defect corrective surgeries
Why the Procedure Is Performed
Some heart defects need repair soon after birth. For others, it is better to wait months or years. Certain heart defects may not need to be repaired.
In general, symptoms that indicate that surgery is needed are:
Blue or gray skin, lips, and nail beds (cyanosis). These symptoms mean there is not enough oxygen in the blood (hypoxia).
Difficulty breathing because the lungs are "wet," congested, or filled with fluid (heart failure)
Problems with heart rate or heart rhythm (arrhythmias)
Poor feeding or sleeping, and lack of growth and development of a child
Common Pediatric Surgeries performed are:
The surgeries described below are done to correct many different heart defects in children.
Patent ductus arteriosus (PDA) ligation
Before birth, there is a natural blood vessel between the aorta (the main artery to the body) and the pulmonary artery (the main artery to the lungs) called the ductus arteriosus. This opening usually closes shortly after birth. A PDA occurs when this opening fails to close.
Sometimes a simple surgery can be done. In this procedure, the surgeon inserts a few small tubes into an artery in the leg and passes them up to the heart. Then, a small metal coil or another device is put into the child’s arteriosus artery. The coil or other device blocks the blood flow, and this corrects the problem.
Another method is to make a small cut, or incision, on the left side of the chest. The surgeon reaches in and ties off the ductus arteriosus, or divides and cuts it. Tying off the ductus arteriosus is called ligation. Read more >>
Coarctation of the aorta repair
Coarctation of the aorta occurs when a part of the aorta has a very narrow section, like in an hourglass timer. To repair this defect, an incision is usually made on the left side of the chest, between the ribs.
The most common way to repair this is to cut the narrow section and make it bigger with a patch made of Gore-tex, a man-made material.
Another way to repair this problem is to remove the narrow section of the aorta and stitch the remaining ends together. This can usually be done in older children.
A third way to repair this problem is called a subclavian flap. First, an incision is made in the narrow portion of the aorta. Then, a patch is taken from the left subclavian artery (the artery to the arm) to enlarge the narrow section of the aorta.
A fourth way to repair the problem is to connect a tube to the normal sections of the aorta, on either side of the narrow section. Blood flows through the tube and bypasses the narrow section.
Atrial septal defect (ASD) repair
The atrial septum is the wall between the left and right atria (upper chambers) of the heart. There is a natural opening before birth that usually closes on its own when a baby is born. When the flap does not close, the child has an ASD.
Sometimes ASDs can be closed without open-heart surgery. First, the surgeon makes a tiny cut in the groin. Then the surgeon inserts tubes into a blood vessel that go into the heart. Next, 2 small umbrella-shaped "clamshell" devices are placed on the right and left sides of the septum. These 2 devices are attached to each other. This closes the hole in the heart. Not all medical centers do this procedure.
Open-heart surgery may also be done to repair ASD. Using open-heart surgery, the septum can be closed using stitches, or sutures. Another way is to cover the septum with a patch made of membrane or a man-made material. Read more >>
Ventricular septal defect (VSD) repair
The ventricular septum is the wall between the left and right ventricles (lower chambers) of the heart. A hole in the ventricular septum is called a VSD.
By age 8 for most children with this problem, small VSDs often close on their own and do not need surgery. This depends on where the hole is.
Larger VSDs, small ones in certain parts of the ventricular septum, or ones that cause heart failure or endocarditis (inflammation) need open-heart surgery. They also require placing a man-made patch over the hole to cover it.
Some septal defects can be closed using heart catheterization (passing a thin tube into the heart). Read more >>
Tetralogy of Fallot repair
Tetralogy of Fallot is a congenital heart defect that usually includes 4 defects in the heart.
Open-heart surgery is needed, and it is often done when the child is between 6 months and 2 years of age.
Different types of repairs are done, depending on the defects. The ventricular septal defect is one repair, and it is described above. The pulmonary valve is opened and the thickened muscle (stenosis) is removed. A patch may be placed on the right ventricle and main pulmonary artery to improve blood flow to the lungs.
The child may have a shunt procedure done first. A shunt moves blood from one area to another. This is done if the open-heart surgery needs to be delayed. A shunt procedure requires making a cut between two of the ribs. Read more >>
Transposition of the great vessels repair
In a normal heart, the aorta comes from the left side of the heart, and the pulmonary artery comes from the right side. Transposition of the great vessels is when these arteries come from the opposite sides of the heart.
Correcting transposition of the great vessels requires open-heart surgery. If possible, this surgery is done shortly after birth.
The most common repair is an arterial switch. The aorta and pulmonary artery are divided. The pulmonary artery is connected to the right ventricle, where it belongs. Then, the aorta and coronary arteries are connected to the left ventricle, where they belong.
Truncus arteriosus repair
Truncus arteriosus is a rare condition that occurs when the aorta, coronary arteries, and the pulmonary artery all come out of one common trunk. This is a very complex defect, and it requires complex open-heart surgery to repair it.
Repair is generally done in the first few days or weeks of the child’s life. The pulmonary arteries are separated from the aortic trunk, and any defects are patched. Usually, there is also a ventricular septal defect, and that is patched. A connection is then placed between the right ventricle and the pulmonary arteries.
Many children need 1 or 2 more surgeries as they grow.
Tricuspid atresia repair
The tricuspid valve is the valve between the upper and lower chambers on the right side of the heart. Tricuspid atresia occurs when this valve is missing. To get to the lungs, blood must cross an atrial septal defect (ASD), ventricular septal defect (VSD), or a patent ductus artery (PDA). (These conditions are described above.) This severely restricts blood flow to the lungs.
Other defects may exist with tricuspid atresia. A medicine called prostaglandin E may be given for a patent ductus arteriosus to maintain it as an alternate channel to the lungs until surgery can be done.
A series of shunts and surgeries may be necessary to correct this defect. The goal of this surgery is to allow blood from the body to flow into the lungs, and blood from the lungs to be pumped to the rest of the body through the left ventricle.
Total anomalous pulmonary venous return (TAPVR) correction
TAPVR occurs when the pulmonary veins bring oxygen-rich blood from the lungs back to the right side of the heart, instead of to the left side of the heart, where it should be.
This condition requires surgery to correct it. When the surgery is done will depend on how sick the baby is. The surgery may be done in the newborn period if the infant has severe symptoms. If it is not done right after birth, it is done in the first 6 months of the baby’s life.
TAPVR repair requires an open-heart surgery. The pulmonary veins are attached to the left side of the heart, where they belong, and any abnormal connections are closed.
If a PDA is present, it is tied off and divided.
Hypoplastic left heart repair
This is a very severe heart defect that results from a severely underdeveloped left heart. If it is not treated, it causes death in most babies who are born with it. Operations to treat this defect are done at specialized medical centers. Usually surgery corrects this defect. A series of 3 heart operations is usually needed.
The first operation is done in the first week of the baby’s life. This is a complicated surgery where one blood vessel is formed from the pulmonary artery and the aorta. This new vessel carries blood to the lungs and the rest of the body.
The second operation is usually done when the baby is 4 to 6 months old.
The third operation is done a year after the second operation.
A heart transplant may be done to treat this condition. But, finding a donor heart for an infant is very difficult. Infant heart transplants can be done only ata few medical centers.
Risks
Hospitals and medical centers that perform heart surgery on children have surgeons, nurses, and technicians who are specially trained to perform these surgeries. They also have staff who will take care of your child after surgery.
Risks for any surgery are:
Additional risks of heart surgery are:
If your child is talking, tell them about the surgery. If you have a preschool-aged child, tell them the day before what will happen. Say, for example, "We are going to the hospital to stay for a few days. The doctor is going to do an operation on your heart to make it work better."
If your child is older, start talking about the procedure 1 week before the surgery. You should involve the child’s life specialist (someone who helps children and their families during times like major surgery) and show the child the hospital and surgical areas.
Your child may need many different tests:
Blood tests (such as complete blood count, electrolytes, clotting factors, and "cross match")
Always tell your child’s doctor or nurse what drugs your child is taking. Include drugs, herbs, and vitamins you bought without a prescription.
During the days before the surgery:
If your child is taking blood thinners (drugs that make it hard for blood to clot), such as warfarin (Coumadin) or heparin, talk with your child’s doctor or nurse about when to stop giving these drugs to the child.
Ask your child’s doctor which drugs the child should still take on the day of the surgery.
On the day of the surgery:
Your child will usually be asked not to drink or eat anything after midnight the night before the surgery.
Give your child any drugs your doctor told you to give your child with a small sip of water.
Your child’s doctor or nurse will tell you when to arrive at the hospital.
After the Procedure
Most children who have open-heart surgery need to stay in the intensive care unit (ICU) for 2 to 4 days right after surgery. They usually stay in the hospital for 5 to 7 more days after they leave the ICU. Stays in the intensive care unit and the hospital are usually shorter for patients who have closed-heart surgery.
During their time in the ICU, your child will have:
A tube in the airway (endotracheal tube) and a respirator to help with breathing. Your child will be kept sleeping (sedated) while on the respirator.
One or more small tubes in a vein (IV line) to give fluids and medicines
A small tube in an artery (arterial line)
One or 2 chest tubes to drain air, blood, and fluid from the chest cavity
A tube through the nose into the stomach (nasogastric tube) to empty the stomach and deliver medicines and feedings for several days
A tube in the bladder to drain and measure the urine for several days
Many electrical lines and tubes used to monitor the child
By the time your child leaves the ICU, most of the tubes and wires will be removed. Your child will be encouraged to start many of their regular daily activities. Some children may begin eating or drinking on their own within 1 or 2 days, but others may take longer.
When your child is discharged from the hospital, parents and caregivers are taught what activities are okay for their child to do, how to care for the incision, and how to give medicines their child may need.
Your child needs at least several more weeks at home to recover. Talk with your doctor about when your child can return to school or daycare.
Your child will need follow-up visits with a cardiologist (heart doctor) every 6 to 12 months. Your child may need to take antibiotics before going to the dentist for teeth cleaning or other dental procedures, to prevent serious heart infections. Ask the cardiologist if this is necessary.
Outlook (Prognosis)
The outcome of heart surgery depends on the child's condition, the type of defect, and the type of surgery that was done. Many children recover completely and lead normal, active lives.
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