Follow up after cardiac surgery

Date last published:

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.

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Cardiology

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

 InvestigationsExplanation
Pre-dischargeECG
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 monthsECG
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
Echocardiogram
Consider Exercise Test moderate asymptomatic group
(consider Holter in infants)

 

Definitions

Mild ASEcho Doppler < 3.5m/secContinuous wave/Peak velocity
Moderate ASEcho Doppler > 3.5 m/sec 
Severe ASEcho Doppler > 4.0 m/sec (mean gradient 40mm Hg) 

*LV strain refer to padiatric cardiology

Arterial Switch Operation (ASO) for D-TGA

 InvestigationsExplanation
Pre-dischargeECG
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 weeksECG
CXR
ECG – specifically look for myocardial ischaemia
CXR – persistent cardiomegaly: consider aorto-pulmonary collaterals
6 monthsECG
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 monthsDobutamine 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 yearsECG
Echocardiogram
Consider MRI or catheterisation at any age if PAs not growing
2-3 yearly thereafterECG
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:

  1. Branch PA stenoses (often seen early)

  2. Progressive aortic dilation +/- aortic regurgitation (usually a medium-long term problem)

  3. 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/managementExplanation
Pre-dischargeECG
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 weeksEchocardiogramHigh 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 monthsEchocardiogramOnly if important residual shunt or significant concerns related to high risk features
12 monthsEchocardiogram
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 reviewEchocardiogram
ECG
If high risk features present but no intervention being considered

Surgical ASD closure

 InvestigationsExplanation
Pre-dischargeECG
Chest x-ray
Echocardiogram
 
4 weeksECG
CXR
 
6 monthsECG
Echo
If no cardiac residua discharge from cardiology follow up

Atrial Septal Defect Primum

(see CAVC Protocol below)

Bidirectional Glenn (BDG)

 Investigations/managementExplanation
Pre-dischargeECG
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 weeksECG
CXR
Saturations
By local paediatrician/cardiologist
6 monthsECG
Echocardiogram
Saturations
Ventricular function
AV/VA valve function
Assess Glenn
12 monthsPlan 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 FontanSaturations – 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

 InvestigationsExplanation
Pre-dischargeECG
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 weeksECG
CXR
Saturations
Local paediatric units use outreach nursing to follow saturations
6 monthsECG
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

 InvestigationsExplanation
Pre-dischargeECG
Chest x-ray
Echocardiogram
4 limb BP
LV function, other residua e.g. bicuspid aortic valve specifically mentioned, evaluation coarctation area & hypertension
4 weeksECG
CXR
Clinical + 4 limb BP
 
4-6 monthsClinical 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 concernsEchocardiogram
4 limb BP
 
Yearly review until aged 5Incl BPby paediatrician or paediatric cardiologist (GPs unlikely to have child sphygmomanometer)
3 yearly check thereafter throughout lifeECG 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)

 InvestigationsExplanation
Pre-dischargeECG
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 weeksECG
CXR
Routine post surgical tests
6-12 monthsECG
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 14-15ECG
Echocardiogram
Transfer to ACHD aged 15

Fontan

Surveillance protocol for uncomplicated Fontans

Interval from operationStandard investigationsExplanation
4 weeksCXR
ECG
Routine investigations
6 monthsEchocardiogram
ECG
Assess: Ventricular function, AV regurgitation, Fontan baffle and Glenn for thrombi, branch pulmonary arteries, pulmonary venous return
1 yearEchocardiogram
ECG
As above
2 yearsEchocardiogram
ECG
As above
3 yearsEchocardiogram
ECG, MRI, CT or cardiac catheter*
LFTs (including albumin), Hgb, creatinine
 
Subsequently
AnnualEchocardiogram
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/managementExplanation
Pre-dischargeChest 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 monthsEchocardiogramAssess device, LV function
PA symmetry
Discharge non-infant coil, Amplatzer and Occlutech devise patients if no residua
12 monthsEchocardiogramPA symmetry
Aortic arch
If no concerns - discharge

Surgical PDA closure

 InvestigationsExplanation
Pre-dischargeECG
Chest x-ray
Echocardiogram
Electrolytes
Routine post-op surgical check
Assess LV size and function, flow into LPA
If infant is on diuretics
4 weeksECG
Chest x-ray
Review medication and ensure diuretics stopped
Discharge if PDA division
Diuretics may be continued in infants with CLD
12 monthsEchocardiogram if murmur present – this can be performed by local paediatric team and discussed with cardiologyLow incidence of late recanalisation

Pulmonary Balloon Valvuloplasty

 InvestigationsExplanation
Pre-dischargeECG
Echocardiogram
RV function
Pulmonary valve peak and mean gradient
Pulmonary regurgitation quantified
Tricuspid regurgitation quantified
3 - 6 monthsECG
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

 InvestigationsExplanation
Pre-dischargeECG
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 weeksECG
CXR
Routine post surgery check (paediatrician or local cardiologist)
6-12 monthsECG
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 intervention

  • Tetralogy 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

 InvestigationsExplanation
Pre-dischargeECG
Chest x-ray
Echocardiogram
If known difficult surgical anastomosis or echo Doppler velocity >1m/s consider early echocardiography review e.g. 3months
4 weeksECG
CXR
 
6 monthsECG
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 yearsECG
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

 InvestigationsExplanation
Pre-dischargeECG
Chest x-ray
Echocardiogram
RV and LV function.  Competence pulmonary homograft, velocities in PAs.  Aortic valve function
4 weeksECG
Chest x-ray
Routine post surgical check (paediatrician or local cardiologist)
6 monthsECG
Echocardiogram
Watch for PA stenosis.  RV function, pulmonary regurgitation.
LV function, aortic (truncal) valve function
yearlyECG
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)

 InvestigationsExplanation
Pre-dischargeECG
Chest x-ray
Echocardiogram
LV and RV function
Specify size of any residual VSD
4 weeksECG
CXR
Routine check by paediatrician usually
(not paediatric cardiologist in outreach clinic)
12 monthsECG
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 yearsECG
Echocardiogram
Further routine appointment only for patients with pre-operative aortic valve prolapse or RV muscle bundle resection.

Ross Procedure

Surveillance protocol

 Standard InvestigationsExplanation
4 weeksCXR
ECG
Routine
6 monthsEchocardiogram
ECG
Assess LV, LVOFT specifically for regurgitation and root dilatation
Subsequently
AnnualEchocardiogram
ECG
 
Every 3 yearsCardiopulmonary 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

 InvestigationsExplanation
Pre-dischargeECG
Echocardiogram
CXR
Assess valve function repair
Ventricular function*
4 weeksECG
CXR
Rhythm
Heart size and lung fields
3-6 monthsEchocardiogram
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 EchocardiogramAssess valve and ventricular function
Any time: mechanical valvesFluoroscopySuspected 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

  1. prosthetic valves:

    1. 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

    2. 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)

    3. The incidence of thromboembolism is higher for the mitral than the aortic position1 (level of evidence B).

  2. Bioprosthetic valves

    1. 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)

 

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