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← Section IV · Congenital Heart Disease
IV.K

Echo Evaluation of Post-Op Congenital Heart Disease

9 cards

Notes

Post-TOF repair

  • Look for:
    • Chronic pulmonary regurgitation - nearly universal after transannular patch. Assess VC width, PR pressure half-time (< 100 ms → severe), holodiastolic reversal in the PA.
    • RV dilation and dysfunction - indication for pulmonary valve replacement (surgical or Melody/Sapien percutaneous).
    • Residual VSD - small residual patch leaks common; hemodynamically significant if Qp:Qs > 1.5.
    • RVOT gradient - residual obstruction.
    • Aortic root dilation - from long-standing volume overload.
    • QRS > 180 ms on ECG - predicts VT/SCD risk.

Post-atrial switch (Mustard / Senning) for d-TGA

  • Systemic RV - assess for failure with RV size, TAPSE, RV S′, FAC.
  • Systemic AV (tricuspid) valve regurgitation - often severe.
  • Baffle stenosis - assess with color/PW at SVC-limb, IVC-limb, PV limbs of the baffle.
  • Baffle leaks - agitated saline injection into an upper extremity vein.
  • Arrhythmia burden (sinus node dysfunction, atrial arrhythmias).

Post-arterial switch (Jatene) for d-TGA

  • Neo-aortic root dilation and neo-AR - the pulmonary root now bears systemic pressure.
  • Coronary ostial stenosis - screen with stress imaging or coronary angiography.
  • Supravalvular PA stenosis / branch PS - from the Lecompte maneuver (PAs draped over aorta).

Post-Fontan (total cavopulmonary connection)

  • Assess:
    • Fontan pathway obstruction (SVC-PA anastomosis, IVC baffle/conduit).
    • Systemic ventricular function.
    • Systemic AV valve regurgitation.
    • Persistent fenestration flow (right-to-left).
    • Thrombus in Fontan circuit.
    • Signs of Fontan failure (elevated CVP, ascites, liver congestion, PLE).

Post-VSD repair

  • Residual small patch leak - usually hemodynamically insignificant.
  • Complete heart block (from suture damage near the AV node) - pacemaker required.
  • Aortic regurgitation - cusp damage or prolapse.
  • Right bundle branch block on ECG is expected after right ventriculotomy.

Post-ASD repair

  • Small residual patch leak - hemodynamically trivial.
  • Residual atrial arrhythmias.
  • Preop RV function is the strongest predictor of post-op RV recovery - timing of closure matters.

Post-coarctation repair

  • Recoarctation - screen with suprasternal notch views.
  • Aneurysm at the repair site - especially after patch aortoplasty.
  • Persistent hypertension - very common even after successful anatomic repair.
  • Cardiovascular events - long-term risk elevated.

Post-Ross operation

  • Neo-aortic root dilation - the autograft (native PV) is now in systemic position and can dilate.
  • Neo-AR - often progresses over decades.
  • RVOT/pulmonary homograft dysfunction - RVOT PS or PR from the homograft in the pulmonary position.

Cards

  • basicIV.K-001
    What is the most common valvular problem to monitor after tetralogy of Fallot repair?
    → Chronic pulmonary regurgitation (nearly universal after a transannular RVOT patch). Assessed with PR pressure half-time (< 100 ms → severe), vena contracta width, holodiastolic PA flow reversal, and progressive RV dilation.
  • basicIV.K-002
    What ECG finding after TOF repair predicts SCD risk?
    → QRS duration > 180 ms predicts ventricular tachycardia and sudden cardiac death.
  • basicIV.K-003
    After atrial switch (Mustard/Senning) for d-TGA, name three important echo findings to look for.
    → 1) Systemic (morphologic) RV dysfunction. 2) Systemic AV (tricuspid) valve regurgitation. 3) Baffle stenosis or leak. Also atrial arrhythmias and sinus node dysfunction.
  • basicIV.K-004
    How is a baffle leak diagnosed after an atrial switch operation?
    → Agitated saline contrast injected into an upper extremity vein — bubbles crossing into the systemic (arterial) circulation indicate a leak from the systemic-venous baffle into the pulmonary-venous baffle.
  • basicIV.K-005
    After Jatene arterial switch, what specific coronary complication should be screened for?
    → Coronary ostial stenosis at the reimplantation site. Ischemia may manifest as regional wall-motion abnormalities on stress imaging or ventricular arrhythmia.
  • basicIV.K-006
    After the Ross operation, what problem may progressively develop over decades?
    → Neo-aortic root dilation and neo-aortic regurgitation — because the pulmonary autograft is now bearing systemic pressures. The pulmonary homograft in the pulmonary position may also degenerate.
  • basicIV.K-007
    What is the most common echo finding to screen for after coarctation repair?
    → Recoarctation (persistent or recurrent narrowing at the repair site) and — after patch aortoplasty — aneurysm formation. Also assess for persistent hypertension.
  • basicIV.K-008
    Which arrhythmia is expected after ventriculotomy for VSD or TOF repair?
    → Right bundle branch block (from disruption of the right bundle during ventriculotomy). Complete heart block from damage near the AV node may occur near the perimembranous VSD — pacemaker dependent.
  • basicIV.K-009
    What are the components of a Fontan pathway assessment on echo?
    → 1) SVC-to-PA anastomosis patency. 2) IVC baffle / extracardiac conduit (look for obstruction, thrombus). 3) Systemic ventricular function. 4) AV valve regurgitation. 5) Fenestration flow direction. 6) Thrombus in the Fontan circuit.