The pediatric challenge of heart surgery

Abstract

Advances in the surgical management of children, in particular neonates with complex and previously lethal congenital heart disease has led to a dramatic improvement in survival. Nevertheless, complex heart surgery is sometimes associated with significant multi-organ disorders. These may originate from an adverse pre-operative condition, from post-operative circulatory failure and from the adverse effects of long-term intensive supportive therapy. Therefore, each neonate with a congenital heart defect must have a thorough workup for associated or genetically determined defects. Metabolic disturbances must be corrected before surgery as far as possible. After surgical correction, organ failure is almost exclusively the result of circulatory failure. Cardiac tamponade, also tamponade without pericardial fluid but by swelling of the heart within the pericardium and closed thorax, must be considered. If circulatory instability persists in spite of adequate heart rate and rhythm, optimized pre- and afterload and optimal myocardial support, the patient must be scrutinized for residual heart defects and surgical reintervention may be strongly indicated. Respiratory failure may be a sign of heart failure. Renal support therapy may facilitate fluid management and may be a lifesaving bridge to total or partial recovery of renal function, provided heart failure is overcome. However, there is no evidence for routine renal replacement therapy to prevent postsurgical multi- organ failure. Children with congenital heart defects can be treated appropriately only within a multidisciplinary team in which pediatric intensivists, heart surgeons, cardioanaesthesiologists, and pediatric cardiologists can rely on a high standard of care from other pediatric disciplines.