THE FAILING RIGHT HEART: THE NEGLECTED CHAMBER - Asian Heart & Vascular Centre
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
THE FAILING RIGHT HEART: THE NEGLECTED CHAMBER
What is the role of the
right heart?
• Facilitates the return of venous blood by
sucking them in
• Feeds the left heart
• Without it, rate of venous return is fixed
• Facilitates increase in cardiac output during
exercise
Can we live without a
right heart?
Natural history: Un-repaired • Well formed single LV: 70% die before 16 years old 4 • Well formed single RV: 50% die 4 years a=er diagnosis 4 • Die of arrhythmias, CCF and sudden unexplained death 4. Moodie DS. Long-term follow-up in the unoperated univentricular heart. Am J Cardiol. 1984;53:1124–1128.
Univentricular repair • Concept – Disconnecting the RV from the circuit – Reconnecting the venous return to the pulmonary arteries – Venous return driven by the “Push and Pull” mechanism
Classic Fontan operation • Distension of the atrial cavity • Pro-arrhythmogenic environment • Pro-coagulant environment
Natural history: repaired
• Lateral tunnel Fontan palliaFon: 91% survival at
10 years.5
5. Stamm C. Long-term results of the lateral tunnel Fontan operation. J Thorac Cardiovasc Surg. 2001;121:28–41.
Surgical correcFon • Presence of a non-dominant ventricle precludes a biventricular repair • Buy Fme for the baby (Bridge to Fontan / Norwood) –Bi-direcFonal cavo-pulmonary connecFon (BCPC) –BT shunt, Waterston, PoTs • Fontan palliaFon
Stage 1: Creation of arterio-venous shunt Classic BT shunt Waterston shunt Modified BT shunt Potts shunt
Classic BT shunt Modified BT shunt
Potts shunt Waterston shuntModified BT shunt
13Stage 2:
Take-down of BT shunt
and creation of
Bidirectional Cavo-
Pulmonary ConnectionCompletion of Fontan: Extra-cardiac Fontan
Extra-cardiac Fontan
17Fontan palliation
Survival in patients with Fontan
palliation
d’Udekem Y, Circulation 2007
Khairy P, Ciculation 2008Case 1 • 20 year old Indian gentleman • Enlisting to NS • Was told to have abnormal ECG and CXR • NYHA functional class 1 • Asymptomatic
Diagnosis?
• Superior sinus venosus (15%)
• Primum (20%)
Text
• Secundum (60%)
• Coronary sinus defect33
34
Trans-thoracic Echo
36
Trans-Oesophageal Echocardiogram
LA
RA
SVC
Bicaval ViewIndications to close: • Haemodynamic impact on the heart • Dilated right heart • Development of pulmonary hypertension • Embolic phenomena
Percutaneous device closure
41DuraFon of anF-platelets
• Aspirin 100mg om for 6 months
• Plavix 75mg om for 2 month
• Repeat TTE in 1 and 6 months Fme
• Time for the right heart to shrink back to
normal size
• Assess for pericardial effusion
• Assess for residual shunts
43Timing&of&ASD&closure&and&its&impact&
on&Survival,&Atrial&size&and&Atrial&
arrhythmias&
4445
46
47
48
SBE prophylaxis
• EndocardiFs prophylaxis is advised for
• PaFents undergoing catheter closure for a
period of 6 months.
• Residual leak a=er device or surgical closurePre-operative
precautions
• Most tolerate GA well.
• Stop warfarin 3-5 days prior to op if patient
has AF
• Bubble or fibrin filter for all intravenous
lines
• Refer to cardiologist if there is a degree of
pulmonary hypertension.Case 2 • 38 year old Indian gentleman • Was told that he needed to close a hole in his heart • Defaulted due to financial reasons • Admitted for joint pain • Hb 19.5, Hct 58.5
Diagnosis?
Blood bypasses the lung
Body compensates by producing more red blood cells
to maintain oxygen delivery to the organsClassification of Pulmonary
Hypertension
• Gp 1: Pulmonary arterial hypertension
• Gp 2: PH due to left heart disease
• PH due to lung disease
• Chronic thromboembolic PH
• PH with unclear multifactorial mechanismsComplications
• Gout
• Secondary • Gallstones
erythrocytosis containing
• Hyperviscosity calcium
bilirubinate
symptoms
• Renal dysfunction
• Iron deficiency • Hyperuricaemia
• Bleeding • Proteinuria
complications
• InfectionManagement
• Call your friendly
cardiologist
• Care with anticoagulation
and anti-platelets
• We want to know early • Treatment with PAH
• Avoidance of relative specific therapy
anemia and iron deficiency
• SBE prophylaxis
• Avoid unnecessary • Good dental hygiene
venesection
• Avoid dehydration Hct < 65 • Aggressive treatment of
infections
• Care must be taken
with diuretics • Flu vaccination
• Fibrin filters with • Long term oxygen
intravenous drips therapySBE prophylaxis • EndocardiFs prophylaxis is advised for • All paFents with Eisenmenger syndrome
Pre-operative
precautions
• Avoid surgery if possible
• Stop warfarin 3-5 days prior to op
• Keep PAH medication
• Adequate hydration
• Bubble or fibrin filter for all intravenous lines
• Local anaesthesia/GA vs RA, minimal PEEPCommitment . Compassion . Comprehensive
Our Heart Team is committed to providing comprehensive
care for all types of heart disease and vascular conditions,
including coronary artery disease, arrhythmia, heart failure,
congential and valvular heart disease, and vascular
disease.
We strive to help people create healthier lives by
integrating nutritional, psychological and exercise
counselling to provide a personalized holistic health care
experience.
www.asianheart.com.sg
DR CHUANG HSUAN-HUNG DR STANLEY CHIA DR JEREMY CHOW DR KENNETH GUO DR TAN CHONG HIOK DR GOH PING PING DR LIM YII HONG
Cardiologist Cardiologist Cardiologist Cardiologist Cardiologist Cardiologist Clinical Exercise Physiologist
Heart Failure Intensivist Interventional Cardiologist Electrophysiologist Congenital Heart Specialist Interventional Cardiologist Cardiovascular Imaging
Mt Elizabeth Novena Specialist Centre Mt Elizabeth Medical Centre Mt Elizabeth Medical Centre Gleneagles Medical Centre
38 Irrawaddy Road #08-58 to 63 3 Mount Elizabeth #17-08 3 Mount Elizabeth #16-07 6 Napier Road #04-13
Singapore 329563 Singapore 228510 Singapore 228510 Singapore 258499
(65) 6339 3638 (65) 6339 3632 (65) 6733 8638 (65) 6733 8630 (65) 6887 3422 (65) 6836 2021 (65) 6473 9698 (65) 6473 7328
enquiry.mnh@asianheart.com.sg enquiry.me@asianheart.com.sg enquiry.meh@asianheart.com.sg enquiry.gmc@asianheart.com.sgThank you
You can also read
