**Anaesthetic considerations**

66 Perioperative Considerations in Cardiac Surgery

(tetralogy, AV canal defect). Communication between two ventricles can be of any size and can occur at any part of septum. Most common type of VSD is peri membranous (also called subaortic or infracristal). Other less common defects are subpulmonary (Supra cristal, infundibular or outlet type), Inlet type (canal type) and muscular. Spontaneous closure is

Smaller defects are not associated with large shunting of blood from left ventricle to right ventricle may not diagnose early in life but they are prone to infective endocarditis. Whereas larger defects cause shunting of blood from left to right ventricle this led to higher pulmonary blood flow and consequently pulmonary congestion. Due to early development of symptoms these patients diagnosed earlier. During systole LV ejects blood not only in the aorta but also in the pulmonary artery causing volume overload of pulmonary vessels, atria and left ventricle. These patients will develop high pulmonary vascular resistance (PVR)

A device like amplatzer can be placed to close few of these defects by interventional cardiologist. This procedure is performed in the cath lab as a daycare procedure but there are certain criteria needs to be fulfilled. There should be an adequate rim around the defects where amplatzer can be placed. Surgically VSD can be approached through ventricle, aorta,

Always consider high pulmonary vascular resistance in these patients and be ready to treat high PVR and right ventricular failure by inhaled NO, dobutamine and milrinone. Desirable haemodynamic goals by anaesthetists are to have slightly higher preload and pulmonary vascular resistance while keeping the SVR on the lower side and at the same time maintaining heart rate and contractility. Up to 10% of patients may develop conduction

Intraoperative transesophageal echocardiography (TEE) will be beneficial in recognizing residual defects, intracardiac air and right ventricular function. Smaller VSD are sometimes becomes apparent after closure of large defect. In uncomplicated VSD closure patient can be

Normally there is no communication between right and left atria due to presence of a septum. This atrial septum composed of septum primum and septum secundum which

Several types of defects can occur in this septum leading to shunting across. Apart from secundum defect other less common are primum, sinus venosus and coronary sinus type. Most common defect is **ostium secundum** which usually located in the centre (also called fossa ovalis type) and occurs due to deficient septum primum. It may be single or have several small defects called fenestrated type. Patent foramen ovale commonly seen at the same site in 25 – 30% of normal patients. Usually PFO do not permit left to right shunting but right to left shunting can occurs if right atrial pressure exceeds left atrial pressure

**Sinus venosus defect** is usually associated with partial anomalous pulmonary venous drainage and appears either at the junction of superior vena cava and atrial septum (High up) or at the junction of inferior vena cava and septum (located lower part of septum).

abnormalities after VSD repair which may be transient or permanent.

merges with endocardial cushion, superior and inferior vena cava.

possible in muscular and membranous type of defects.

and if untreated will leads to Eisemenger.

pulmonary artery or right atrium.

extubated in the operating room.

**6.2 Atrial septal defect (ASD)** 

(sneezing, valsalva)

Repair some time may cause injury to SA node.

**Anaesthetic considerations** 

Inhalation induction in infants and very young and intra venous induction in older children is acceptable technique. Intramuscular ketamine can be alternative for induction or intra venous line placement in some children. Pulmonary hypertension is generally not seen in these patients and their management is usually simple with the goals of higher preload and slightly high PVR to reduce pulmonary flow. Presence of ASD is not usually poses higher risk for infective endocarditis.

TEE is helpful to see the residual ASD, mitral valve repair (primum type), four pulmonary veins opening in left atrium (Sinus venosus type). Tracheal extubation in the operating room will help in minimizing the charges.
