Pediatric Anesthesiology
Congenital Heart Disease - 4
V. Long term and/or post-op CHD
A. Long term cyanosis or pressure overload leads to myocardial fibrosis with diminished contractility.
B. Univentricular hearts become myopathic during the 2nd-3rd decade.
C. Residual lesions
- Shunts
- Palliative for cyanosis
- Blalock-Taussig: subclavian -> pulmonary artery (PA)
- Waterston: ascending Ao -> right PA
- Potts: descending Ao -> left PA
- Glenn: SVC -> right PA
- Residual VSD, ASD
- Valve insufficiency
- TOF: pulmonary insufficiency
- AV canal: mitral regurge
- AS: aoritc insufficiency
- Increasing PVR after shunt closure
- Hypertension after coarct repair
- Electrophysiologic sequelae
- RBBB after ventriculotomy
- Atrial arrhythmia: ASD, Mustard
- Ventricular arrhythmia: TOF, ventriculotomy
- Prosthetic materials
- Physiologic repairs which produce a systemic RV: RV functions less well than LV and may
deteriorate over time
- CNS redidua
- Cerebral venous thrombosis in cyanosis
- Cerebral abscess
- Aneurysm with coarctation
VI. Infective endocarditis prophylaxis
American Heart Association Recommendations, 2007:
A. Antibiotic prophylaxis is recommended for patients with the following underlying cardiac conditions that are associated with the highest risk of adverse outcome from infective endocarditis for dental procedures that involve manipulation of the gingiva or the periapical region of teeth or the perforation of oral mucosa (excluding local anesthetic injection through noninfected tissue):
- Prosthetic cardiac valve or prosthetic material used for cardiac valve repair
- Previous infective endocarditis
- The following CHD only:
- Unrepaired cyanotic CHD, including palliative shunts and conduits
- Completely repaired CHD with prosthetic material or devices, whether placed by surgery or catheter intervention, during the first 6 months after the procedure. (Endothelialization of prosthetic material occurs within 6 months after the procedure.)
- Repaired CHD with residual defects at the site or adjacent to the site of a prosthetic patch or prosthetic device (which inhibit endothelialization).
- Cardiac transplant recipients who develop cardiac valvulopathy
B. The following procedures do NOT need prophylaxis
- Routine anesthetic injection through noninfective tissue
- Taking dental radiographs
- Placement of removable prosthodontic or orthodontic appliances
- Adjustment of orthodontic appliances
- Placement of orthodontic brackets
- Shedding of deciduous teeth
- Bleeding from trauma to the lips or oral mucosa
C. Recommended antibiotic regimen for infective endocarditis prophylaxis
Not allergic to penicillin:
- Able PO: amoxicillin 50 mg/kg to 2 Gm PO
- Unable PO: ampicillin 50 mg/kg to 2 Gm IV or IM, or cefazolin or ceftriaxone 50 mg/kg to 2 Gm IV or IM
Allergy to penicillin:
- Able PO: cephalexin 50 mg/kg to 2 Gm, or clindamycin 20 mg/kg to 600 mg, or azithromycin or clarithromycin 15 mg/kg to 500 mg PO
- Unable PO: cefazolin or ceftriaxone 50 mg/kg to 1 Gm IV or IM, or clindamycin 20 mg/kg to 600 mg IV or IM
NOTE: cephalosporins should NOT be used in an individual with history of anaphylaxis, angioedema or utricaria with penicillin or ampicillin
Reference: Wilson W, Taubert KA et al. AHA Guideline. Prevention of Infective Endocarditis. Circulation 116:1736-54, 2007