THE FAILING RIGHT HEART: THE NEGLECTED CHAMBER - Asian Heart & Vascular Centre

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THE FAILING RIGHT HEART: THE NEGLECTED CHAMBER - Asian Heart & Vascular Centre
THE FAILING RIGHT HEART:
THE NEGLECTED CHAMBER
THE FAILING RIGHT HEART: THE NEGLECTED CHAMBER - Asian Heart & Vascular Centre
THE FAILING RIGHT HEART: THE NEGLECTED CHAMBER - Asian Heart & Vascular Centre
THE FAILING RIGHT HEART: THE NEGLECTED CHAMBER - Asian Heart & Vascular Centre
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
THE FAILING RIGHT HEART: THE NEGLECTED CHAMBER - Asian Heart & Vascular Centre
Can we live without a
    right heart?
THE FAILING RIGHT HEART: THE NEGLECTED CHAMBER - Asian Heart & Vascular Centre
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.
THE FAILING RIGHT HEART: THE NEGLECTED CHAMBER - Asian Heart & Vascular Centre
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
THE FAILING RIGHT HEART: THE NEGLECTED CHAMBER - Asian Heart & Vascular Centre
Classic Fontan operation
• Distension of the atrial
  cavity
• Pro-arrhythmogenic
  environment
• Pro-coagulant
  environment
THE FAILING RIGHT HEART: THE NEGLECTED CHAMBER - Asian Heart & Vascular Centre
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.
THE FAILING RIGHT HEART: THE NEGLECTED CHAMBER - Asian Heart & Vascular Centre
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
33
34
Trans-thoracic Echo
36
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
45
46
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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 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
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