Pediatric and Adult Congenital Cardiac Surgery
Congenital surgery is not only pediatric
Secundum atrial septal defects and perimembranous ventricular septal defects are usually closed electively at 3–5 years, or earlier with failure to thrive, aortic regurgitation, or pulmonary hypertension. The non-negotiable contraindication is pulmonary vascular disease with a net right-to-left shunt: closing an Eisenmenger defect removes the pop-off and precipitates right heart failure. Adults with unrepaired defects need calculated pulmonary vascular resistance, not just an echocardiographic gradient.
The Fontan circulation deserves separate thinking. It works with low pulmonary artery pressure, low resistance, and unobstructed flow; a fenestration protects the ventricle at the cost of cyanosis. Late complications include atrial arrhythmia, conduit stenosis, thromboembolism, protein-losing enteropathy, plastic bronchitis, and Fontan-associated liver disease, so surveillance is lifelong. Reoperations for conduit degeneration, baffle leaks after Mustard or Senning repair, and neo-aortic dilation after arterial switch require teams comfortable with redo sternotomy.
Traps
Endocarditis prophylaxis is indicated for prosthetic material and residual lesions, not for an uncomplicated repaired or native secundum ASD. Pregnancy counseling should precede conception, because Eisenmenger syndrome carries a high maternal mortality and Fontan patients need multidisciplinary planning. Anomalous left coronary artery from the pulmonary artery presents in infancy with irritability and mitral regurgitation, and delay costs ventricular function.
Rule of thumb
Estimate shunt fraction from saturations: Qp/Qs = (SaO2 − mixed venous O2)/(pulmonary venous O2 − PaO2). A ratio above 1.5 generally indicates a hemodynamically significant left-to-right shunt.