Simple Tetralogy of FallotPostoperative management made simple

(…in 20 minutes) Stephane LE BEL Hôpital Timone-Enfant

• Theseverlycyanosedneonate/infant• ModifiedBlalock-Taussig-Thomasshunt• RVOTstentingprocedure• Rightventriculetopumonaryarteryconnection• Completeneonatalsurgicalrepair

• Completesurgicalrepair

• RV-PAconduit

• Melodyprocedure

The Anesthetist and Intensivist task Risk management

• SentinalThreat:Anatomy–Comobidities...• ApicalErrors:Intheoperativetheater.• Additionalerrorchain:InPICU

OddsratioofMorbidity• Neonates5,26(3,90-7,09)p<0,001• Complexity2,14(1,67–3,12)p<0,001• Bypass>90’2,28(1,67–3,12)p<0,001• Ilnessseverity1,52(1,16–2,00)p<0,01

Pulmonary to Systemic Anastomosis

« It is never just a BT shunt »

• 173children➢Medianage22days➢Medianweight3,2kg

• AcuteEventson41patients➢Chestopening(n=30)➢ShuntThrombosis(n=16)➢Pulmonaryovercirculation(n=17)

➢Death(n=6)

Primary Issues with BT shunt

1. Volumeloadingoftheheart• Fluids-Transfusion• Valvularregurgitation• Subendocardialischemia

2. Coronarysteal• Shuntsize-lenght–anastomosis–PulmonaryvsSystemicresistances• Lowdiastolicpressure(PAd<30mmHg)• Subendocardialischemia

3. Shuntthombosis• Platelets(anypro-coagulantfactor)• Hemoglobin>15g/dl• PulmonaryArterialHypertension• LowCardiacoutput• Technicalissues

How to deal quickly with a complex physiology?

• SpO2<75%vs>85%

• NIRScerebral/renalratio<1vs>1• ECG(ischemia)• InvasiveArterialpressure(PAd)• Arterialgastest(Hb;PaO2;Lactates)• Echocardiography• Pulmonaryechography• Cathlab/Tomodensitometry

• Hypotensionanddesaturation➢Hypovolemia(realorfunctional)–anemia➢Highpulmonaryandlowsystemicvascularresistance

➢Shuntocclusion/thrombosiswithhypoxemicheartfailure

➢Pulmonarydeseasewithlowpulmonaryveinsaturation

• Hypotensionandhighsaturation➢Highcardiacoutputwithvasodilatation➢Pulmonaryovercirculationwithsystemicvasoconstirction

• NormalPAm/PAdandlowSpO2➢TechnicalIssues➢HighPVR-PAHT➢HighO2consumption

RVOT and Ductal stenting are high-risk procedures

Neonatalinterventionalcatheterism• Allcausemortality12%

➢1stprimarycause:Cardiac65,1%➢2ndprimarycause:Pulmonary(16,6%)

• AdverseEvents30,2%• MajorAE4,2%

• Atwomonthinfant,withT4F,severlydesaturated,avlocardyl,twofluidchallenge,nonInvasiveventilatorysupport(CPAP),schedulledforRVOTstentingprocedure

• CRISP=9➔ SeriousAdverseEvents=8-10%

RVOT / Ductal stenting

Nonspecificissues

• Poorpatientaccess• Poorlighting• Radiationexposure• Offsitelocation• Lowambienttemperature• Frequentflushings• Positioningissues• Bleeding• Vasculartrauma/thrombosis• Dysrythmia• Vascular/cardiacchamberperforation• Stroke/airembolism

Specificissues

• Patentductusarteriosus?➢ Alprostadilinducedmorbidities

• ComplexDAanatomy

• Guidingandstentpositioning➢ Fluidchalenge➢ Esmolol➢ Vasopressor

• Emergentsurgery

• Greaterneedforreintervention

Infavorofarteriosusstenting:• Fewerproceduralcomplication• ShorterICULOS• Lessdiuretics• Nodifferenceinthehazardsofacompositeoutcome(death+unplannedinterventiontotreatcyanosis)

• 52patients• 1per-proceduredeath• 1emergentsurgery• 2BTSshuntforinadequateoxygenation.• 16re-catheterization

➢Baloonangioplasty➢Re-stentprocedure

TOF complete surgical repair

• JunctionalEctopicTachycardia• Postoperatiebleeding• LowCardiacOutputSyndrome

➢Tamponade➢RVSystolicdysfunction➢RVDiastolicdysfunction

• Residuallesions➢BranchPAstenosis➢ResidualRVOTobstruction➢Residual/newVSD

• Ileus/Poorenteralfeeding

• RightVentricularDysfunction➢RVmusclehypertrophylimitscardioplegiaefficiency

➢RVOTrésectionandrelatedarythmie/heartblock

➢RVhypetrophyanddiastolicdysfunction

• ResidualVDS>4-5mm• RVOTvelocities>3m/s• Pulmonaryregurgitation

Postoperative clinical pathway

Day0• Volemia

➢RAP≈ 5-10mmHG(15mmHg)• HR<150/mn

➢T°control(SIRS)➢Analgesia-Dexmedetomidine➢SuMg+;Adénosine;amiodarone

• NormalBloodPressure➢Vasoplegia(SIRS–volemia–vasopressor)➢LCOS(milrinone)➢PFO++

• 1153TOFrepairs(92centers)• Mortality0,13%• EarlyExtubation(<H+6h)31%• Medianventilationduration20,9h• EarlyExtubationassociatedfactors:

➢Higherweight➢Lesserskinincisiontoskinclosuretime.

➢Lesseraorticcrossclampingtime

Right Ventricule to Pulmonary Conduit

• Redosurgery• Lowmorbidityrelatedtopre-CPBdissectiontimeandcomplication(bleeding)• Fasttrackpathway• ShortICUstay

Percutaneous Pulmonary Valvulation

• Patientcomorbidities:➢Rightventricularfailure➢Distalpulmonaryarterystenosis

• Generalanesthesia• Prolongedprocedure• Pressureinjury• Plexusinjury

• Hemoptysis• ICU/CCUadmissionunfrequent

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11:07 11:30 11:53 12:16 12:39 13:02 13:25 13:48 14:11 14:34 14:57 15:20 15:43RightCerebRsO2 LelCerebRsO2

•Initialimprovmentofglobalhemodynamics.

•ProgressivedecreaseofcerebralRsO2.

•IncreseadamplitudeofcerebraldesaturationwithiterativeRV-PAangioplasty.

Iterative balloon inflations led to an impaired hemodynamic status with poor tolerance in a 14 years old girl with repaired TOF and right

ventricular systolic failure

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RightCerebRsO2LelCerebRsO2

Conclusion

• Mortalityandmorbiditybelongtothecohortofprofundlydesaturedneonates.• Surgicalorpercutaneousinterventionarehighriskprocedureinthiscontext.• AnesthesiologistandIntensivistaretheonesconfrontedwithmorbiditiesoccurrenceandtreatment.• Wellknownneonatalpalliativeprocedurevsnewpercutaneoustechnique?• Howcanweimproveneonatalacutecare?• Howcanwepreventordecreasetheoccurrenceofpostoperativeadverseevents?