THE FAILING RIGHT HEART: THE NEGLECTED CHAMBER - Asian Heart & Vascular Centre
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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
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 shunt
Modified BT shunt 13
Stage 2: Take-down of BT shunt and creation of Bidirectional Cavo- Pulmonary Connection
Completion of Fontan: Extra-cardiac Fontan
Extra-cardiac Fontan 17
Fontan palliation
Survival in patients with Fontan palliation d’Udekem Y, Circulation 2007 Khairy P, Ciculation 2008
Case 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 defect
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Trans-thoracic Echo
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Trans-Oesophageal Echocardiogram LA RA SVC Bicaval View
Indications to close: • Haemodynamic impact on the heart • Dilated right heart • Development of pulmonary hypertension • Embolic phenomena
Percutaneous device closure 41
DuraFon 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 43
Timing&of&ASD&closure&and&its&impact& on&Survival,&Atrial&size&and&Atrial& arrhythmias& 44
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SBE prophylaxis • EndocardiFs prophylaxis is advised for • PaFents undergoing catheter closure for a period of 6 months. • Residual leak a=er device or surgical closure
Pre-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 organs
Classification 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 mechanisms
Complications • Gout • Secondary • Gallstones erythrocytosis containing • Hyperviscosity calcium bilirubinate symptoms • Renal dysfunction • Iron deficiency • Hyperuricaemia • Bleeding • Proteinuria complications • Infection
Management • 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 therapy
SBE 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 PEEP
Commitment . 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.sg
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