Follow up after cardiac surgery
These guidelines are for follow up of the more common cardiac lesions managed by the Paediatric and Congenital Cardiac Services at Starship Children’s Hospital.
- Aortic Stenosis (AS)
- Arterial Switch Operation (ASO) for D-TGA
- Atrial Septal Defect (secundum ASD)
- Atrial Septal Defect Primum
- Bidirectional Glenn (BDG)
- Blalock-Taussig and Central Shunts
- Coarctation of the Aorta
- Complete Atrioventricular Canal (CAVC)
- Fontan
- Patent Ductus Arteriosus
- Tetralogy of Fallot
- Total Anomalous Pulmonary Venous Drainage
- Truncus Arteriosus
- Ventricular Septal Defect (VSD)
- Ross Procedure
- Surgical valve replacement/repair
- References
- Document Control
These guidelines are for follow up of the more common cardiac lesions managed by the Paediatric and Congenital Cardiac Services at Starship Children’s Hospital. They are applicable in situations where the post-operative course has been uncomplicated with a predicted outcome. They do not supersede discharge planning that has been instituted and documented after the patient has been discharged at the time of cardiac surgery.
If there is any uncertainty, the cardiology team should be contacted for clarity or guidance.
Aortic Stenosis (AS)
Post-operative follow-up for either aortic balloon dilatation or surgical aortic valvotomy
Investigations | Explanation | |
---|---|---|
Pre-discharge | ECG Chest x-ray Echocardiogram | LV function, hypertrophy, valve morphology Aortic peak and mean gradient Any regurgitation quantified |
4 weeks (post surgery) | ECG CXR | Routine post-surgical tests |
4 months | ECG Echocardiogram (+/- sedation) | LV function, hypertrophy Aortic peak and mean gradient Aortic regurgitation quantified |
Follow-up thereafter every 1-2 years depends on severity of AS/AR (many in this group may have mixed valve disease) | ||
Stable/mild AS every 2 years Moderate/severe AS every year | ECG |
Definitions
Mild AS | Echo Doppler < 3.5m/sec | Continuous wave/Peak velocity |
Moderate AS | Echo Doppler > 3.5 m/sec | |
Severe AS | Echo Doppler > 4.0 m/sec (mean gradient 40mm Hg) |
*LV strain refer to padiatric cardiology
Arterial Switch Operation (ASO) for D-TGA
Investigations | Explanation | |
---|---|---|
Pre-discharge | ECG Chest x-ray Echocardiogram | Discharge letter should specifically comment on ventricular and semilunar valve function, the arterial and pulmonary anastomosis and the size and peak velocity of the branch pulmonary arteries. |
4 weeks | ECG CXR | ECG – specifically look for myocardial ischaemia CXR – persistent cardiomegaly: consider aorto-pulmonary collaterals |
6 months | ECG Chest x-ray Echocardiogram (preferably with sedation) with visiting paediatric cardiologist. Consider return to Starship if inadequate images and sedated echo cannot be performed locally | Main residua to exclude is pulmonary artery branch stenosis: If PAs well seen on an echo at 6 months, no loud murmur and no asymmetry on CXR can defer next echo until aged 2-3 years If suspect PA branch stenosis or above not met, for MRI scan |
12 months | Dobutamine stress echo and coronary CT scan (under GA at Starship) | Only in patients with intramural coronary arteries or concerns flagged at time of surgery related to coronary re-implantation |
Yearly | Clinical review by paediatrician or paediatric cardiologist yearly. | |
Aged 2-3 years | ECG Echocardiogram | Consider MRI or catheterisation at any age if PAs not growing |
2-3 yearly thereafter | ECG Echocardiogram | Watch for dilating proximal aorta/AR Watch for PA growth (unlikely a problem if growing well first 5 years) |
Aged 12-15 years (pre-transition) | Exercise test Cardiac MRI scan | In view of coronary surgery, helps with exercise recommendation. Provides better imaging of branch PAs and aorta |
Most important sequelae are:
Branch PA stenoses (often seen early)
Progressive aortic dilation +/- aortic regurgitation (usually a medium-long term problem)
Coronary artery stenosis – an infrequent but important complication – note that due to effective cardiac denervation these patients will often not experience typical angina symptoms.
Atrial Septal Defect (secundum ASD)
Transcatheter ASD closure
Investigations/management | Explanation | |
---|---|---|
Pre-discharge | ECG Echocardiogram Inform of endocarditis prophylaxis for 6 months Aspirin for 6 months after implantation | Define size of any residual leak Quanity MR and TR |
4 weeks | Echocardiogram | High risk features: Deficiency of any rims, device size >5mm larger than static ASD diameter, residual shunt, larger device for weight at implant (> 20mm in adult or body weight:device size ratio <3.0), other concerns as defined by implanting cardiologist. |
3 months | Echocardiogram | Only if important residual shunt or significant concerns related to high risk features |
12 months | Echocardiogram ECG | Consider discharge from Cardiology if no high risk features, normal size and function of RV. Residual leak with dilated RV – review with consideration for quantification/intervention |
2 yearly review | Echocardiogram ECG | If high risk features present but no intervention being considered |
Surgical ASD closure
Investigations | Explanation | |
---|---|---|
Pre-discharge | ECG Chest x-ray Echocardiogram | |
4 weeks | ECG CXR | |
6 months | ECG Echo | If no cardiac residua discharge from cardiology follow up |
Atrial Septal Defect Primum
(see CAVC Protocol below)
Bidirectional Glenn (BDG)
Investigations/management | Explanation | |
---|---|---|
Pre-discharge | ECG Chest x-ray Echocardiogram Saturations Head circumference Wound care plan and drain suture removal | Sinus rhythm/ischaemia Effusions Ventricular function, AV regurgitation, VA regurgitation, Glenn pathway Set expected level for patient at follow up Clear timeline for this to occur |
4 weeks | ECG CXR Saturations | By local paediatrician/cardiologist |
6 months | ECG Echocardiogram Saturations | Ventricular function AV/VA valve function Assess Glenn |
12 months | Plan timing of cardiac catheterisation Saturations ECG CXR | Early catheter 12 months postop: - if previous Norwood/arch reconstruction, - if surgical plasty of pulmonary arteries at time BDG - if saturations in 70s - consider if ventricular dysfunction Later catheter > 2 years post Glenn prior to Fontan: - if asymptomatic, growth good, ventricular function normal, echo reassuring |
Present at Cardiosurgical conference after catheter | ||
Year 2 and 3 prior to Fontan | Saturations – every visit ECG – yearly CXR – yearly Echo – as at 6 months If saturations < 80% consider cardiac cath / rule out P.A.V.M.S. | Cardiology: minimal yearly review in local centre Paediatric review for growth, feeding, non-cardiac issues may need to be more frequent Community/outreach nursing services check saturations minimal 6 monthly |
Note: all BDGs to remain on aspirin 3-5 mg/kg/day
Blalock-Taussig and Central Shunts
Excludes patients on Single Ventricle Palliation pathway
Investigations | Explanation | |
---|---|---|
Pre-discharge | ECG Chest x-ray Echocardiogram Saturations | All patients on aspirin 3-5mg/kg State level saturation in discharge letter Discharge letter state & plan follow-up by PCCS |
4 weeks | ECG CXR Saturations | Local paediatric units use outreach nursing to follow saturations |
6 months | ECG CXR Echocardiogram Saturations | Individualised follow-up plan for cardiac CT and surgery e.g. Tetralogy of Fallot with pulmonary stenosis 6-12 months Tetralogy with pulmonary atresia/confluent PAs : 12 months or > 8kg (as need PA conduit) |
Coarctation of the Aorta
Investigations | Explanation | |
---|---|---|
Pre-discharge | ECG Chest x-ray Echocardiogram 4 limb BP | LV function, other residua e.g. bicuspid aortic valve specifically mentioned, evaluation coarctation area & hypertension |
4 weeks | ECG CXR Clinical + 4 limb BP | |
4-6 months | Clinical check especially pulses BP Sedated echo | Needs imaging of repair site, and measurements of full arch to detect arch hypoplasia. Images to be reviewed by Cardiologist |
1 year if concerns | Echocardiogram 4 limb BP | |
Yearly review until aged 5 | Incl BP | by paediatrician or paediatric cardiologist (GPs unlikely to have child sphygmomanometer) |
3 yearly check thereafter throughout life | ECG and BP at visit Echocardiogram (3 yearly) Ambulatory BP Monitor MRI | Yearly check BP by GP Ambulatory BP monitoring and MRI aged around 10 years |
Complete Atrioventricular Canal (CAVC)
Investigations | Explanation | |
---|---|---|
Pre-discharge | ECG Chest x-ray Echocardiogram | LV and RV function Comment on VSD, ASD, repair Quantify left and right AV valve regurgitation (AVVR) Exclude AVV stenosis Assess for conduction abnormalities |
4 weeks | ECG CXR | Routine post surgical tests |
6-12 months | ECG Echocardiogram | |
If no residua for 3-4 yearly follow-up 5 yearly after aged 10 if no or minor AV valve regurgitation If > mild AVVR 1 – 2 yearly follow-up with echocardiogram | ECG Echocardiogram | Follow for AVVR LVOT obstruction, more common in non-Trisomy 21 |
Aged 14-15 | ECG Echocardiogram | Transfer to ACHD aged 15 |
Fontan
Surveillance protocol for uncomplicated Fontans
Interval from operation | Standard investigations | Explanation |
---|---|---|
4 weeks | CXR ECG | Routine investigations |
6 months | Echocardiogram ECG | Assess: Ventricular function, AV regurgitation, Fontan baffle and Glenn for thrombi, branch pulmonary arteries, pulmonary venous return |
1 year | Echocardiogram ECG | As above |
2 years | Echocardiogram ECG | As above |
3 years | Echocardiogram ECG, MRI, CT or cardiac catheter* LFTs (including albumin), Hgb, creatinine | |
Subsequently | ||
Annual | Echocardiogram ECG | |
Every 2 years (starting from 5 years from Fontan) | LFTs including albumin | |
Every 4 years (starting from 7 years after Fontan) | Abdominal US, CPX, MRI from ~ 10 years onward |
* unless cardiac catheterisation undertaken earlier for fenestration closure
Patent Ductus Arteriosus
Transcatheter PDA closure
Investigations/management | Explanation | |
---|---|---|
Pre-discharge | Chest X-ray at 4 hours Echocardiogram at four hours Second dose of antibiotics at 4 hours Same day discharge if meets criteria | Device site Assess device/residual shunt, LPA and arch PA and aorta velocities. LV function Access site okay, up to toilet, eating/drinking, 4 hours elapsed from procedure and before 7pm. |
6 months | Echocardiogram | Assess device, LV function PA symmetry Discharge non-infant coil, Amplatzer and Occlutech devise patients if no residua |
12 months | Echocardiogram | PA symmetry Aortic arch If no concerns - discharge |
Surgical PDA closure
Investigations | Explanation | |
---|---|---|
Pre-discharge | ECG Chest x-ray Echocardiogram Electrolytes | Routine post-op surgical check Assess LV size and function, flow into LPA If infant is on diuretics |
4 weeks | ECG Chest x-ray Review medication and ensure diuretics stopped | Discharge if PDA division Diuretics may be continued in infants with CLD |
12 months | Echocardiogram if murmur present – this can be performed by local paediatric team and discussed with cardiology | Low incidence of late recanalisation |
Pulmonary Balloon Valvuloplasty
Investigations | Explanation | |
---|---|---|
Pre-discharge | ECG Echocardiogram | RV function Pulmonary valve peak and mean gradient Pulmonary regurgitation quantified Tricuspid regurgitation quantified |
3 - 6 months | ECG Echocardiogram | If no significant gradient (<2.5 m/sec velocity) Consider discharge or 5 year follow-up If moderate PS (3 – 4 m/sec velocity) for continued follow-up |
Tetralogy of Fallot
Investigations | Explanation | |
---|---|---|
Pre-discharge | ECG Chest X-ray Echocardiogram | Record at discharge if any temporary complete block & duration (as for any patient undergoing intracardiac repairs) Echo : LV & RV function, VSD assessment, RVOT and PA assessment (peak velocities & size) |
4 weeks | ECG CXR | Routine post surgery check (paediatrician or local cardiologist) |
6-12 months | ECG CXR Echocardiogram | If evidence PA stenosis, or residual VSD consider cardiac catheterization early If only residua is pulmonary regurgitation plan follow-up for serial RV function |
Interval follow-up thereafter 2 - 5 yearly depending on residua | Clinical ECG CXR Echocardiogram MRI | Paediatrician review yearly up to age 5 years (growth, learning & developmental issues): Rhythm, serial measurement QRS, QTc PA symmetry, heart size RV function/dilation, RVOT and PA assessment If concern RV function, better PAs especially distal |
Tetralogy of Fallot variants:
Tetralogy of Fallot and MAPCAs
All patients to return for cardiac catheterisation 6 -12 months (as specified in discharge summary. To be booked at discharge). This is to measure RV and PA pressure, balloon dilate any peripheral pulmonary stenoses and plan likely follow-up/expected need for further interventionTetralogy of Fallot: Pulmonary Valve Replacement
Protocol of follow up: all pts to have 1 year full review to include ECG, CXR, exercise test with measured oxygen consumption, echo, and MRI.
Total Anomalous Pulmonary Venous Drainage
Investigations | Explanation | |
---|---|---|
Pre-discharge | ECG Chest x-ray Echocardiogram | If known difficult surgical anastomosis or echo Doppler velocity >1m/s consider early echocardiography review e.g. 3months |
4 weeks | ECG CXR | |
6 months | ECG Echocardiogram | Pulmonary closure should be normal intensity on examination RVH should have resolved on ECG and echo Anastomosis wide without acceleration Consider use of sedation to obtain adequate study |
4-5 years | ECG Echocardiogram | As above Discharge after this review if all veins and the anastomosis are seen well, stenosis is excluded, and pulmonary hypertension is excluded. Consider alternative imaging if uncertain |
This protocol does not include scimitar, or any patient with any residua where long term FU is required.
Truncus Arteriosus
Investigations | Explanation | |
---|---|---|
Pre-discharge | ECG Chest x-ray Echocardiogram | RV and LV function. Competence pulmonary homograft, velocities in PAs. Aortic valve function |
4 weeks | ECG Chest x-ray | Routine post surgical check (paediatrician or local cardiologist) |
6 months | ECG Echocardiogram | Watch for PA stenosis. RV function, pulmonary regurgitation. LV function, aortic (truncal) valve function |
yearly | ECG Echocardiogram | Neonatal PA homografts/conduits usually need replacement as too small by 5 years, but great variation |
Lifetime follow up by cardiology | Conduits inevitably need replacement |
Ventricular Septal Defect (VSD)
Investigations | Explanation | |
---|---|---|
Pre-discharge | ECG Chest x-ray Echocardiogram | LV and RV function Specify size of any residual VSD |
4 weeks | ECG CXR | Routine check by paediatrician usually (not paediatric cardiologist in outreach clinic) |
12 months | ECG Echocardiogram | If VSD closed, no residua, normal conduction on ECG and no developmental concerns: Discharge from follow-up. If residual VSD or other residua, follow-up as appropriate. Consider cardiac catheterization if residual VSD >small |
4-5 years | ECG Echocardiogram | Further routine appointment only for patients with pre-operative aortic valve prolapse or RV muscle bundle resection. |
Ross Procedure
Surveillance protocol
Standard Investigations | Explanation | |
---|---|---|
4 weeks | CXR ECG | Routine |
6 months | Echocardiogram ECG | Assess LV, LVOFT specifically for regurgitation and root dilatation |
Subsequently | ||
Annual | Echocardiogram ECG | |
Every 3 years | Cardiopulmonary exercise test |
Consider MRI if:
Progressive ascending aorta dilatation
Significant conduit regurgitation with RV EDA > 22cm²/m²
RV dysfunction
Surgical valve replacement/repair
Patients who have undergone valve replacement are not cured but still have serious heart disease¹
Investigations | Explanation | |
---|---|---|
Pre-discharge | ECG Echocardiogram CXR | Assess valve function repair Ventricular function* |
4 weeks | ECG CXR | Rhythm Heart size and lung fields |
3-6 months | Echocardiogram ECG | Assess valve and ventricular function, r/o para |
* Ventricular remodellling takes months rather than weeks to occur following correction of mitral or aortic valve regurgitation: hence role of early serial echo questionable | ||
Yearly: whether prosthetic or bioprosthetic** some valve repairs can be every 2 years if pristine early | ECG or Echocardiogram | Assess valve and ventricular function |
Any time: mechanical valves | Fluoroscopy | Suspected mechanical valve dysfunction |
** AHA and other guidelines recommend yearly assessment of prosthetic valves¹
The routine recommendation for homograft and bioprosthetic valves is also yearly follow up – it has long been recognised that valve repairs and homografts with no deterioration in the first 1-2 years may remain event free for years: cardiologist discretion to space to 2 yearly follow up.
Anticoagulation
Anticoagulation regimen should be stated on the operative report and the discharge summary
prosthetic valves:
lifelong anticoagulation with warfarin and INR monitoring is recommended1 (Class 1 recommendation, level of evidence A p556-558) Target INR prosthetic mitral valve 2.5-3.5 Prosthetic aortic valve 2.0-3.0
Aspirin 75 mg to 100 mg daily is recommended in addition to anticoagulation with warfarin in patients with a mechanical valve prosthesis¹ (566,567). (Level of Evidence: A. Data is from studies in adults, some with other comorbidities)
The incidence of thromboembolism is higher for the mitral than the aortic position1 (level of evidence B).
Bioprosthetic valves
Aspirin 75 mg to 100 mg per day is reasonable for a bioprosthetic aortic or mitral valve (572–575). (CLASS IIa, level of evidence: B)