**9. Post-operation Management**

The post-operative management of patients following successful repair should be similar to that of other high-risk cardiac surgery patients. However, there are several key princi‐ ples that must be remembered. As these patients often present and are taken to the oper‐ ating room in acute decompensated heart failure, strict attention to optimizing biventricular function is critical. Post-operative left ventricular dysfunction is common and there should be a low threshold for placement of an intra-aortic balloon pump (IABP), particularly if one was not placed pre-operatively. While, as discussed below, the use of an IABP is often associated with worse outcomes, the relationship to a poor outcome is the need for its use and the potential delay in initiating therapy rather than the therapy itself that influences the adverse outcome. Right heart failure is common and often these patients require con‐ siderable therapies directed specifically at assisting in right heart management. Convention‐ al intravenous agents such as epinephrine, milrinone, and dobutamine are often required – and sometimes at high doses. Inhaled agents that selectively reduce pulmonary vascu‐ lar resistance and assist in reducing RV afterload such as inhaled nitric oxide (20-80 ppm) or epoprostenol (2,500 – 20,000 ng/min) may be required [37]. Ventricular arrhythmias are also common from the residual ischemic/necrotic myocardium (as well as secondary to the ventriculotomy) and anti-arrhythmic medications, such as amiodarone, should be used lib‐ erally. In addition, as the repaired septal defect and free wall are often quite friable, strict attention to avoid hypertension is important as even transient elevations in blood pres‐ sure can result in disruptions in either the patch repair or the ventriculotomy closure su‐ ture line that might precipitate uncontrolled and fatal cardiac bleeding. Any acute increase in chest tube drainage should raise the concern for ventricular suture line dehiscence and there should be a low threshold for returning the patient to the operating room for reexploration – however, excess manipulation of the heart in the search for bleeding should be avoided at the risk of catastrophic suture-line tearing in a beating and pressurized ven‐ tricle. Any post-operative coagulopathy must be aggressively corrected. Although recov‐ ery in these patients is unpredictable, it may be prolonged. A slow wean of inotropes may be required and there should be a low threshold for repeat and/or frequent echocardiograph‐ ic evaluations in a patient who is not improving as anticipated. Repeat echocardiography might show a residual shunt or valvular dysfunction, more importantly may identify easy to correct problems, such as tamponade.
