New Proceedings In The Cardiovascular Surgery Approach

Surgery for congenital heart disease has undergone very rapid changes in recent years. Significant improvements have been obtained in the results, in terms of operative and remote mortality, more precise anatomical correction and better hemodynamic and electrophysiological results. This improvement has included the majority of congenital heart diseases and is fundamentally related to a better diagnostic and preoperative management of cardiac defects by incorporating more powerful diagnostic tools (echocardiography, color Doppler, etc.), to the invention, development and application of new surgical techniques, improvement of postoperative management and the association of interventional catheterization to surgery. Of great importance has also been a progressive maturation in the cardiovascular surgery approach that includes: the progressive acceptance of the advantages of primary repair of defects at an early age, even of the newborn, instead of palliation followed by subsequent correction of defects cardiac; open heart palliative surgery in newborns or infants, in those patients who by physiology or anatomy it is not possible to correct their injury. The wide application of Fontan's physiology, that is, achieving an operation of the circulatory system when there is no venous ventricle joining directly the systemic veins to the pulmonary arteries; and its various modifications such as shunt, total pulmonary cavus or other variants for the treatment of complex cardiopathies, such as single ventricle, left heart hypoplasia, etc . And to heart and cardiopulmonary transplantation in the child and newborn. Of children born with congenital heart disease, approximately 1/3 of them require surgery during the first year of life. If they are not treated, most die in the first months of life. Untreated survivors will present damage to multiple organs, mainly the heart, lung and central nervous system. Primary repair surgery reduces the mortality caused by the primary defect and prevents secondary damage to the different organs. In the past, newborns with severe congenital heart disease were treated in the first stage with palliative surgery, followed later by corrective surgery, several years later. This palliative surgery, although it can be considered life saving, in many cases can cause damage to the circulatory system. Such is the case of pulmonary systemic shunts that produce an overload of volume and pressure to the pulmonary circulation. On the other hand, the banding of the pulmonary artery signifies a significant pressure overload in the right (or only) ventricle, which in the medium term can produce structural abnormalities to the heart, such as narrowing of the bulbo-ventricular foramen. The alterations of the pulmonary architecture are also especially serious. Distortion and interruption of the pulmonary arteries are frequently seen after pulmonary artery shunt and bandin, which sometimes contraindicate corrective surgery, especially in Fontan operations. This type of considerations, in addition to others of economic nature (higher accumulated cost of several operations) and epidemiological (death of patients awaiting corrective operations), have made even more evident the advantages of primary corrective surgery, maintaining palliative surgery only for those cases that due to physiology or anatomy are not repairable in the period of newborn or minor infant. This is how a cardiovascular surgeon can perform even in newborns with the following pathologies: transposition of large arteries, total anomalous pulmonary venous drainage, tetralogy of Fallot, ventricular septal defect, truncus arteriosus, complete atrioventricular canal, interruption of the aortic arch, critical aortic stenosis, critical pulmonary stenosis. For those patients with non-reparable heart diseases, palliative surgery plays a fundamental role. The ideal situation for the cardiovascular surgeon in relation to congenital heart diseases is to obtain in the patient a normal circulation with a biventricular heart, however, in many patients this is not possible. There are a large number of patients who have a single ventricle associated with one or two atrioventricular valves and one or two efferent arteries. With the current level of scientific knowledge, the best that can be offered to these patients is the application of Fontan's physiology, which means the direct union of the systemic veins to the pulmonary arteries, obtaining the separation of the venous, pulmonary and systemic blood.