The Pediatric Cardiac Surgery in Iran
Pediatric Cardiology in Iran: Heart Disorders and Diseases in Children
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Pediatric cardiology: Rhythm disorders
Abnormalities in heart rate, or regularity of rhythm, are common in children with heart disease. Their hearts beat too slowly, too fast, or irregularly. These disorders can also occur, but more rarely, in children whose hearts are otherwise normal.
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Pediatric cardiology: Functional disorders
Many children experience “fleeting abnormalities” during growth, despite the absence of any underlying pathology. They are sometimes spectacular: syncope, chest pain, heart murmur, etc. These functional pathologies must be explained to reassure the child and his entourage.
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Pediatric cardiology: Dilated cardiomyopathies
Dilated cardiomyopathy is a disease of the heart muscle. This results in decreased function and dilation of one or both ventricles. It is hereditary or develops after birth. They are characterized by fatigue, shortness of breath on exertion, breathing difficulties first during exercise and then at rest, and discomfort during effort or rest.
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Pediatric cardiology: Hypertrophic cardiomyopathies
Hypertrophic cardiomyopathy is a heart muscle disease that causes a thickening of the wall of one or two ventricles. This thickening can lead to poor function of the affected ventricle. And be accompanied by abnormalities in the propagation of electricity in the heart, which can induce cardiac rhythm disturbances, essentially ventricular. Hypertrophic cardiomyopathies are often hereditary.
The treatment of heart disease in Pediatric cardiology: when and how to treat?
More or less half of children with a cardiac abnormality require intervention at a ‘certain’ moment, either by interventional catheterization or by surgery.
An intervention is never proposed if it does not benefit the child. This benefit can be immediate but can also be long-term.
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Drugs
Except for certain infectious complications such as bacterial endocarditis or purulent pericarditis, where antibiotic treatment can cure the heart attack, and in some rare cases of cardiomyopathy of metabolic origin, where treatments aimed at correcting the metabolic deficit can heal the heart, there is currently no curative medical treatment for cardiac abnormalities, whether congenital or acquired.
However, medications are necessary to help the child in the pre-or post-operative period, treat specific inflammatory syndromes with cardiac involvement, treat rhythm disturbances, and prevent complications in children who have been operated on.
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‘Open’ heart surgery or ‘closed’ heart surgery: Two types of surgeries depending on the needs
1-Open heart surgery or surgery with extracorporeal circulation:
To intervene inside the heart, it is necessary to use the extracorporeal circulation (CEC) or artificial heart-lung machine, which makes it possible to ensure the circulation and oxygenation of the blood. At the same time, the surgeon works on the heart. For this, when the chest is open, the surgeon drifts out of the body through a system of pipes the blue blood from the two vena cava to an artificial lung. The blood oxygenated by the artificial lung is then propelled by a pump into the aorta.
The CEC circuit constitutes a considerable volume that must be “filled with liquid (blood)” before connecting it to the patient’s circulation. The blood must be anticoagulated to avoid the formation of clots in the pipes. When the CEC is connected, the heart and the pulmonary circulation are emptied of their blood, which allows them to be opened without blood loss and without the surgeon being visually hindered by the blood (“open heart surgery”).
Often, the heart will have to be stopped during the procedure (cardioplegia), but the operation can sometimes be done “with a beating heart.” Cardioplegia is achieved by injection into the coronary arteries of a particular cold solution. In specific malformations, it is sometimes necessary to stop the CEC for a while (“total circulatory arrest”). This is possible for short moments at the typical values of hypothermia. However, when the circulatory arrest must be prolonged, the patient is cooled further, up to temperatures between 15 and 20 ° C. It is now possible to operate on infants weighing 2 kg, sometimes less, under CEC.
2-Closed-heart surgery without extracorporeal circulation :
Extracorporeal circulation is often unnecessary when the surgeon intervenes in the vessels outside the heart (aorta, pulmonary arteries). The surgeon then clamps the vessels he must work to stop the blood flow temporarily.
Does surgery always make it possible to correct the heart at once in Pediatric cardiology?
Unfortunately not. Some interventions will be corrective from the outset, but others will be palliative. Sometimes, reinterventions must be carried out for a variable time after the correction.
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The purpose of palliative surgery is either to prepare for corrective surgery because the latter is too complex to be performed at one time (the name “preparatory surgery” would be more appropriate) or to improve tolerance in a child whose heart defect or general condition does not allow a correction from the outset.
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Corrective surgery can be performed immediately (the most frequent case in point) or after preparatory and palliative surgery. Some abnormalities (the minority) are corrected “with a closed heart”: ductus arteriosus, coarctation of the aorta, double aortic arch, etc. In all cases, including intracardiac abnormalities, it is necessary to open the heart and therefore resort to a CEC. With the progress of intensive care for small infants, the miniaturization of CEC techniques, and the increasing accuracy of diagnostics, the current trend is to correct most malformations immediately (without palliation) and at an early age.
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For the most part, the re-interventions are planned and scheduled well in advance: it is generally a question of replacing a prosthesis (most often valvular) or an abnormal valve that the restorative surgery has voluntarily left in place. More rarely, they are due to an unpredictable new fact: bacterial endocarditis, loosening of sutures on a repair, recurrence of an anomaly, maladaptation of the correction with growth, etc. Finally, they are sometimes the result of residues or sequelae that are not very disabling in childhood and which we prefer to carry out the “adjustment” after the end of growth. These interventions are mostly done under CEC. They are technically more difficult due to the adhesions created by the first surgical time, and they may take longer, but the results are generally good.
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Re-interventions are frequently poorly accepted by the patient and his family, mainly since they are performed, if possible, before the onset of symptoms: the patient hardly admits to being operated on again when he feels perfectly healthy. Psychological help at this time is sometimes necessary.