SURGICAL THERAPIES

If the medical treatment aids the patient to tolerate the consequences of the heart disease, only surgery is capable to correct it and to restore a normal circulation.

Concerning the technical methods, cardiosurgical interventions may be subdivided into two groups, namely closed- and open-heart surgery. Closed-heart surgery does not require the opening of the heart and the discontinuation of the blood circulation (heart-lung machine). The heart continues to exert its function during surgery. Examples of these surgical operations are: ligation of patent Botallus duct, surgery for aortic coarctation and palliative Blalock-Taussig interventions or the bandage of the pulmonary artery. On the contrary, open-heart surgery requires a transient discontinuation of the heart function and its replacement by the heart-lung machine which performs the extracorporeal circulation. The heart-lung machine is a pump which pushes the blood into an oxygenator which oxygenates it. During surgery, it is often necessary to lower the body temperature of the child, since this reduces the oxygen consumption. Hypothermia has the purpose of protecting the brain, which is the organ most susceptible to oxygen deficiency. When surgery is concluded, extracorporeal circulation is stopped and the heart starts to beat again spontaneously or with the aid of an electric stimulation. After surgery, the child is carried to an Intensive Care Unit, where it is possible to care for him/her from the respiratory point of view and to monitor blood pressure, heart rate, ECG, introduction of fluids, production of urine, respiratory activity, etc., and to administer the necessary drugs. The patient is unable to feed and, therefore, food is administered by intravenous route.

After a period of intensive care, whose length ranges from one to several days, the patient progressively recovers a self-standing respiratory function, the ability of feeding, and the need of monitoring or drugs is always less frequent. Therefore, he/she is transferred to a general ward and, usually, after 4 or 5 days, he/she is able to rise and, if no complications occur, after 10 days, he/she may be discharged. The recovery of complete activity occurs in a few weeks.

Concerning the ability of resolving the heart disease, surgery may be palliative, corrective or palliative resolution.. Due to the patientıs conditions or to the complexity of the heart disease, it is not always possible to immediately perform a surgery of definitive correction.

In these cases, a so-called palliative surgery is carried out, which does not correct the core heart disease, but relieves its circulatory consequences. In this way the child improves from the clinical point of view, may grow regularly and could reach ­ with no risks ­ the time when the definitive correction of the heart disease may be performed. The typical palliative surgery is carried out in several heart diseases which cause cyanosis (tetralogy of Fallot, pulmonary atresia, etc.), in which the pulmonary flow is extremely reduced. The technique adopted most usually is the one of Blalock-Taussig consisting in a connection between subclavian artery and pulmonary artery.

-Fig. 6.2
Blalock ­ Taussig intervention in Tetralogy of Fallot. The large arrow indicates right subclavian artery connected to the pulmonary artery-.
Intervento di Blalock-Taussig nella Tetralogia di
The objective of this surgery (at closed heart and with a low risk) is to increase the blood flow to the lungs and, thus, to reduce the cyanosis. Some months or some years after palliative surgery, the radical correction of the heart disease may be performed. On the contrary, there are some situations in which at present it is not possible, with a surgical intervention, to restore a normal cardiac anatomy.

These are cases of complex heart diseases, such as the single ventricle, atresia of tricuspid valve, etc. In these cases, a surgery is performed which is unable to restore a regular cardiac anatomy (and thus it is a palliative surgery), but which is at the top level of the present cardiosurgery, thus named "palliative resolved surgery".

By this kind of surgery, a normalization of anatomy is not obtained, but it is possible to separate the systemic from pulmonary circulation, always with a great improvement of patientıs conditions. The risk related to cardiosurgery depends on several factors: type of heart disease, childıs age and conditions prior to surgery. Therefore, it is impossible to quantify exactly the risk of a specific operation. In general, the simplest surgeries have a risk of about 1-2%. This percentage rises to 8-10% for the more complex surgeries. Of course, the indication to surgery views this risk and matches it to the risks and disadvantages of not performing surgery. The majority of children operated on for congenital heart diseases will be able to exert a physical activity equal to that of their peers.

Sometimes, small residual defects could persist, which require no treatment. Rarely some patients require a new surgery, to remove any important residual defect. In very few cases, surgery could create complications which cause a rhythm disorder and, in some of these cases, it is necessary to implant a pacemaker.

A successful surgery resolves all the problems related to the heart function, the child grows and develops regularly and has no disorders. Of course, in children which also show, besides the heart disease,

mental handicaps, the correction of the heart disease does not change these aspects.

The cardiosurgical scar is rather large. In the majority of open-heart surgeries, a vertical cut of the sternum (or median sternotomy) is made. After surgery, the sternum is sutured by metal wires. In other cases surgery is performed through a side chest cut (thoracotomy) which is performed in the space between two ribs and is less visible than the scar of median sternotomy. In the first period after surgery, sternotomy the scar is quite visible, but, with the passing of time, it becomes paler and thinner and, thus, really less visible.

When surgery is made on girls, in some cases, the chest opening may be done with a horizontal cut below the breasts, which will be covered and made invisible by the breast.

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