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To avoid the cumulative morbidity and mortality associated with initial palliative procedures followed by later repair, primary corrective surgery has become increasingly common for patients with congenital heart disease. One result of this trend is that an increasing number of cardiac surgery procedures are performed on neonates and even on premature infants. Optimal care of these infants requires specialized knowledge of the unique structural and functional characteristics of neonatal organ systems and is best accomplished by a multidisciplinary team including cardiology, cardiac surgery, neonatology, anesthesia, and critical care. The purpose of this chapter is to review general principles of care for these infants. The physiology and surgical procedures pertinent to specific defects are discussed in Chapters 6, 7, and 8.

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Cardiac surgery procedures are classified as to whether they are open or closed and whether they are corrective or palliative (Table 13-1). “Open” refers to those procedures in which cardiopulmonary bypass is used; bypass is not used in “closed” procedures. Palliative procedures are performed in patients in whom complete correction of the cardiac defects is not possible or not feasible because of comorbidities. Palliated patients have residual intracardiac shunting or other hemodynamic abnormalities. In most institutions, palliative procedures are only performed for infants with a functional single ventricle (eg, hypoplastic left heart syndrome, tricuspid atresia) or for those with poorly developed pulmonary arteries.

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Table 13-1. Classification of Cardiac Surgery Procedures
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Most corrective procedures, for example, for truncus arteriosus or transposition of the great arteries, are performed by use of cardiopulmonary bypass. Venous blood is siphoned to a reservoir of the heart-lung bypass machine, which also collects blood drained from the operative field by suction catheters. Blood is pumped through an oxygenator, a heat exchanger, and a filter and then returned to the patient’s ascending aorta through an aortic cannula. The patient is always fully anticoagulated with heparin while on bypass.

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Hypothermia extends the safe duration of cardiopulmonary bypass in neonates and infants. Metabolic activity and thus, oxygen consumption, are decreased. “Deep” hypothermia involves cooling to about 18°C. For many years surgeons combined deep hypothermia with either low-flow bypass (25%-50% of normal flow) or more commonly, with no bypass flow, arresting the heart (deep hypothermic circulatory arrest). Deep hypothermic circulatory arrest provided the surgeon with a bloodless and relaxed heart not attached to multiple cannulas that may distort the surgical field. This technique allowed intricate surgical procedures ...

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