Cyanosis surgery

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:

Recommendation for surgery in cyanotic heart disease

Recommendation for surgery in cyanotic congenital heart disease

Indications for repair of a scimitar vein in Anomalous pulmonary venous connection (TAPVC) (Class I, Level of Evidence B ):

❑ Decreased functional capacity ❑ Right ventricle enlagment ❑ Net left to right shunt or QP/QS > 1.5/1 ❑ Pulmonary artery systolic pressure less than 50% systemic pressure ❑ Pulmonary vascular resistance less than 1/3 of systemic resistance ❑ Repair at the time of closure of a sinus venous defect or ASD ❑ Definition: abnormal connection between pulmonary veins and systemic veins leading to right heart volume overload such as ASD

Indications for surgery in Anomalous Pulmonary Venous Connections (TAPVC)(Class 2a, Level of Evidence B) :

❑ Asymptomatic adults with right ventricle volume overload ❑ Large left to right shunt( QP/QS > 1.5/1 ❑Pulmonary artery pressure <50% systemic pressure and pulmonary artery resistance <1/3 systemic resistance ❑ Evidence of Right ventricle volume overload and QP/QS>1.5/1

Synchronized cardioversion : (Class I, Level of Evidence B)

❑ Highly effective in termination of AVRT ❑ In unstable hemodynamic or stable hemodynamic and ineffectiveness of vagal maneuver or adenosin is recommended ❑ Avoidance of complications associated antiarrhythmic drugs ❑ In the presence of PVC or PAC just after cardioversion, antiarrhythmic drugs is recommended for prevention of restarting AVRT ❑ In the presence of hemodynamically unstable and preexcited AF, synchronized cardioversion is recommended

Ibutilide or intravenous procainamide:(Class I, Level of Evidence C)

❑ effective in hemodynamic stable and preexcited AF by slowing conduction over the accessory pathway Contraindications: Compromised left ventricular function

Intravenous diltiazem,verapamil ,beta blockers : (Class 2a, Level of Evidence B-C)

❑ Effective for acute treatment of orthodromic AVRT with out pre-excitation on resting ECG during sinus rhythm(LOR=B) ❑ Intravenous diltiazem or verapamil effectively terminate 90% to 95% of AVRT with out pre-excitation on their resting sinus-rhythm ECG ❑ Hypotension may occur in 3% patients receiving Intravenous diltiazem or verapamil ❑ Intravenous beta blocker are effective for terminating AVRT with low risk of associated complications(LOR=C)

Intravenous betablockers,diltiazem,verapamil (Class 2b, Level of Evidence B):

❑ Acute termination of orthodromic AVRT with pre-excitation on resting ECG with out response to other treatment ❑ Complication is enhancing conduction over the accessory pathway if the AVRT converts to AF during administration of the medication

Intravenous digoxin,intravenous amiodarone,intravenous or oral beta blockers,diltiazem,verapamil : (Class 3, Harm, Level of Evidence B)

❑ Harmful in acute termination of peexcitated AF due to increased risk of ventricular fibrillation by these mechanisms: ❑ Increased conduction over the accessory pathway and slowing or blocking conduction over AV node ❑ Deceased refractory period of accessory pathway by digoxin ❑ Increased cathecolamin due to drug induced hypotension such as amiodarone, beta blocker, verapamil, diltiazem