A primer for the student joining the congenital cardiac surgery service tomorrow: Primer 3 of 7.

Central MessageThis primer prepares students to be acting members of the congenital cardiac surgery service, separated into 3 phases of care: preoperative, perioperative, and postoperative. This primer prepares students to be acting members of the congenital cardiac surgery service, separated into 3 phases of care: preoperative, perioperative, and postoperative. Congenital cardiac surgery corrects structural abnormalities of the heart and great vessels.1Mavroudis C. Backer C.L. Atlas of Pediatric Cardiac Surgery. Springer, 2015Crossref Google Scholar Often, these defects coexist with genetic syndromes and other congenital malformations; therefore, patient management relies heavily on an interdisciplinary approach.1Mavroudis C. Backer C.L. Atlas of Pediatric Cardiac Surgery. Springer, 2015Crossref Google Scholar,2Javed F. Aleysae N.A. Al-Mahbosh A.Y. Zubani A.A. Atash A.M. Salem H.B. et al.Complications after surgical repair of congenital heart disease in infants. An experience from tertiary care center.J Saudi Heart Assoc. 2021; 33: 271-278Crossref PubMed Scopus (1) Google Scholar Congenital cardiac malformations can also be isolated acquired defects.1Mavroudis C. Backer C.L. Atlas of Pediatric Cardiac Surgery. Springer, 2015Crossref Google Scholar Congenital cardiac surgery services often operate on a wide range of patients, from neonates to adults.1Mavroudis C. Backer C.L. Atlas of Pediatric Cardiac Surgery. Springer, 2015Crossref Google Scholar It is common for patients to have multiple procedures, which further complicates their surgeries and perioperative management.3Kaiser L. Kron I.L. Spray T.L. Mastery of cardiothoracic surgery. Lippincott Williams & Wilkins, 2013Google Scholar This primer covers pediatric congenital heart disease; however, the field continues to evolve, and patients are living into late adulthood. Many patients require reoperations as adults.3Kaiser L. Kron I.L. Spray T.L. Mastery of cardiothoracic surgery. Lippincott Williams & Wilkins, 2013Google Scholar This primer discusses the nuts and bolts of being on the congenital cardiac surgery service, separated into 3 phases of care: preoperative (clinic and consults), perioperative, and postoperative (patient management). For overall preparation of a cardiac surgery rotation, please refer to the first primer within this series, “A Primer for the Student Joining the Adult Cardiac Surgery Service Tomorrow.” The embryological basis for defect is shown in Table 1.Table 1Embryological basis for defect4Kloesel B. DiNardo J.A. Body S.C. Cardiac embryology and molecular mechanisms of congenital heart disease: a primer for anesthesiologists.Anesth Analg. 2016; 123: 551-569Crossref PubMed Scopus (45) Google Scholar,4Kloesel B. DiNardo J.A. Body S.C. Cardiac embryology and molecular mechanisms of congenital heart disease: a primer for anesthesiologists.Anesth Analg. 2016; 123: 551-569Crossref PubMed Scopus (45) Google ScholarConditionEmbryological basis for defectPersistent truncus arteriosusFailure of septum formation that divides the truncus arteriosus into aorta and pulmonary arteryDouble-outlet right ventricle1Mavroudis C. Backer C.L. Atlas of Pediatric Cardiac Surgery. Springer, 2015Crossref Google Scholar,6Hooper S.B. Te Pas A.B. Lang J. van Vonderen J.J. Roehr C.C. Kluckow M. et al.Cardiovascular transition at birth: a physiological sequence.Pediatr Res. 2015; 77: 608-614Crossref PubMed Scopus (143) Google ScholarIncorrect alignment of the aorticopulmonary septum in the truncus arteriosus results in aberrant septation, wherein both great vessels arise from the right ventricle.Total anomalous pulmonary venous connection (TAPV)Two theories:(1)The malrotation of the infundibulum prevents clockwise rotation of the aorta toward the left ventricle, which results in displacement of the aorta overriding the right ventricle.(2)Linear rotation instead of spiral rotation of the aortopulmonary septum.Tetralogy of Fallot (TOF)Caused by 2 embryological defects:(1)An anterocephalad deviation of the primitive ventricular outflow tract.(2)Abnormal morphology of hypertrophied trabecular muscle that encircles the subpulmonic outflow tract induces right ventricular outflow tract obstruction.Ebstein anomalyFailure of leaflet delamination and the continued adherence to the ventricular myocardium causes isolated apical displacement of the tricuspid valve leaflet hinge point with the valve orifice remaining in the normal position. The space between the right ventricle and tricuspid valve hinge point becomes atrialized, leading to varying degrees of tricuspid valve insufficiency.Hypoplastic left heart syndromeFailure of delamination or atresia of the mitral valve reduces ventricular filling. The decreased myocardial strain that normally serves as a myocyte growth stimulus results in hypoplasia of the left ventricle. Open table in a new tab 1.Formation of the 3 germ layers (gastrulation): ectoderm, mesoderm, and neuroderm.2.Establishment of the first and second heart fields: primitive streak migration results in a “cardiac crescent” and the establishment of poles.3.Formation of the heart tube: folding of the germ layers in the craniocaudal and lateral axes brings the endocardial tubes and the lateral plate mesoderm together toward the midline, which fuses into a tube-like structure.4.Cardiac looping, convergence, and wedging: the 4 chambers of the heart are formed, and spiraling of aortopulmonary trunk takes place (Figure E1).5.Formation of septa: separation of atrium and creation of the atrioventricular (AV) canals.6.Development of the outflow tracts.7.Formation of cardiac valves.8.Formation of vasculature: coronary arteries, aortic arches, and sinus venosus.9.Formation of the conduction system.5Gittenberger-de Groot A.C. Bartelings M.M. Deruiter M.C. Poelmann R.E. Basics of cardiac development for the understanding of congenital heart malformations.Pediatr Res. 2005; 57: 169-176Crossref PubMed Scopus (197) Google Scholar, 6Hooper S.B. Te Pas A.B. Lang J. van Vonderen J.J. Roehr C.C. Kluckow M. et al.Cardiovascular transition at birth: a physiological sequence.Pediatr Res. 2015; 77: 608-614Crossref PubMed Scopus (143) Google Scholar, 7Marty M. Kerndt C.C. Lui F. Embryology, Fetal Circulation [Updated 2022 May 8].in: StatPearls. StatPearls Publishing, 2023Google Scholar Oxygenated blood is carried from the placenta through the umbilical vein and is partially distributed to the fetal hepatic circulation, with a majority of blood entering the systemic circulation through the inferior vena cava (IVC), bypassing the liver via the ductus venosus. The blood then travels from the IVC to the right atria, where the direction of flow allows it to cross the foramen ovale into the left atrium. The blood then flows into the left ventricle and into the aorta, which is pumped to the brain (greatest oxygen concentration) or mixed with partially oxygenated blood from the ductus arteriosus, which gets pumped to the rest of the body.6Hooper S.B. Te Pas A.B. Lang J. van Vonderen J.J. Roehr C.C. Kluckow M. et al.Cardiovascular transition at birth: a physiological sequence.Pediatr Res. 2015; 77: 608-614Crossref PubMed Scopus (143) Google Scholar,8Remien K. Majmundar S.H. Physiology, Fetal Circulation. [Updated 2022 Jun 19].in: StatPearls. StatPearls Publishing, 2023Google Scholar Deoxygenated blood from the body comes in through the superior vena cava (SVC) and into the right atria. The downward flow mixes with the oxygenated blood from the IVC and sends partially oxygenated blood into the right ventricle. The partially oxygenated blood enters the right ventricle and is pumped into the pulmonary artery. The blood bypasses the lungs through the ductus arteriosus into the aorta, which mixes with the oxygenated blood to the rest of the body. Deoxygenated blood returns to the placenta through 2 umbilical arteries. A diagram of fetal circulation is shown in Figure 1. Classification of congenital heart defects are listed in Table 2, and common genetic syndromes associated with congenital heart disease are detailed in Table 3.6Hooper S.B. Te Pas A.B. Lang J. van Vonderen J.J. Roehr C.C. Kluckow M. et al.Cardiovascular transition at birth: a physiological sequence.Pediatr Res. 2015; 77: 608-614Crossref PubMed Scopus (143) Google Scholar,8Remien K. Majmundar S.H. Physiology, Fetal Circulation. [Updated 2022 Jun 19].in: StatPearls. StatPearls Publishing, 2023Google ScholarTable 2Classification of congenital heart defectsCyanoticTetralogy of FallotRight ventricular hypertrophy, VSD, overriding aorta, right ventricular outflow obstructionTransposition of the great vesselsAnatomic reversal of aorta and pulmonary arteryTricuspid valve atresiaAbsent or rudimentary tricuspid valveEbstein anomalyMalformation of tricuspid valve and atrialization of right ventricleTotal anomalous venous returnAll pulmonary veins drain into systemic circulationPersistent truncus arteriosusSingle trunk that receives output from both ventriclesHypoplastic left heart syndromeSpectrum of disease with severe hypoplasia of the left ventricleAcyanoticAtrial septal defectHole connecting right and left atriaVSDHole connecting right and left ventriclePatent foramen ovaleFailure of atrial septum primum to fuse with septum secundumPatent ductus arteriosusFailed closure of the ductus arteriosusCoarctation of the aortaNarrowing of the aortic isthmusEndocardial cushion defectDefect of the atrioventricular valesSee “Surgical Case Descriptions” section for a more in-depth description of defects. VSD, Ventricular septal defect.1Mavroudis C. Backer C.L. Atlas of Pediatric Cardiac Surgery. Springer, 2015Crossref Google Scholar,4Kloesel B. DiNardo J.A. Body S.C. Cardiac embryology and molecular mechanisms of congenital heart disease: a primer for anesthesiologists.Anesth Analg. 2016; 123: 551-569Crossref PubMed Scopus (45) Google Scholar,5Gittenberger-de Groot A.C. Bartelings M.M. Deruiter M.C. Poelmann R.E. Basics of cardiac development for the understanding of congenital heart malformations.Pediatr Res. 2005; 57: 169-176Crossref PubMed Scopus (197) Google Scholar Open table in a new tab Table 3Common genetic syndromes associated with congenital heart disease4Kloesel B. DiNardo J.A. Body S.C. Cardiac embryology and molecular mechanisms of congenital heart disease: a primer for anesthesiologists.Anesth Analg. 2016; 123: 551-569Crossref PubMed Scopus (45) Google Scholar,5Gittenberger-de Groot A.C. Bartelings M.M. Deruiter M.C. Poelmann R.E. Basics of cardiac development for the understanding of congenital heart malformations.Pediatr Res. 2005; 57: 169-176Crossref PubMed Scopus (197) Google ScholarCongenital heart defectAssociated syndromesTetralogy of FallotDiGeorge syndromeTrisomy 21Transposition of the great arteriesMaternal diabetesHypoplastic left heart syndromeTrisomy 13Trisomy 18Turner syndromeJacobsen syndromeTotal anomalous venous returnHeterotaxy syndromesPersistent truncus arteriosusDiGeorge syndromeTricuspid valve atresiaTrisomy 21 Open table in a new tab See “Surgical Case Descriptions” section for a more in-depth description of defects. VSD, Ventricular septal defect.1Mavroudis C. Backer C.L. Atlas of Pediatric Cardiac Surgery. Springer, 2015Crossref Google Scholar,4Kloesel B. DiNardo J.A. Body S.C. Cardiac embryology and molecular mechanisms of congenital heart disease: a primer for anesthesiologists.Anesth Analg. 2016; 123: 551-569Crossref PubMed Scopus (45) Google Scholar,5Gittenberger-de Groot A.C. Bartelings M.M. Deruiter M.C. Poelmann R.E. Basics of cardiac development for the understanding of congenital heart malformations.Pediatr Res. 2005; 57: 169-176Crossref PubMed Scopus (197) Google Scholar O2 saturation: <90% in right foot/hand or >3% difference between right foot and hand. Blood gas analysis + lactate: acidosis and elevated lactate. Blood pressure: difference >20 mm Hg between arms and legs.9Elsherif Z. Mahmood N. Jamil S. Wagas H. Complex congenital heart disease in a complicated and precious pregnancy.BMJ Case Rep. 2015; 2015bcr2015209388PubMed Google Scholar,10Holst K.A. Said S.M. Nelson T.J. Cannon B.C. Dearani J.A. Current interventional and surgical management of congenital heart disease: specific focus on valvular disease and cardiac arrhythmias.Circ Res. 2017; 120: 1027-1044Crossref PubMed Scopus (49) Google Scholar -Quantifies intracardiac hemodynamics-Ventricular function -Predicts ventricular pressure-Mean and peak transvalvular gradients∗Right ventricular pressures/pulmonary artery systolic pressures are estimated using the tricuspid regurgitation velocity, (normal range for peak TR velocity is <2.8 m/s) -Direction of blood flow-Velocity and turbulence-Identification of shunts Sinus: position of the organs in the body.-Sinus solitus: normal-Sinus inversus: mirror image-Sinus ambiguous: other Cardiac position: the center of mass of the heart relative to the midline.-Levoposition: toward the left-Mesoposition: central-Dextroposition: toward the right Apex orientation: the orientation of the base-to-apex axis of the heart.-Levocardia: toward the left-Mesocardia: midline-Dextrocardia: toward the right 1.Location and position of the heart: sinus, cardiac position, apex orientation.2.Venous return, atria, and interatrial septum.3.AV connections and AV valves. Asses chamber size (concentric/eccentric hypertrophy). Presence of chamber connections. Examples: Biventricular: one atria is connected to one ventricle.-Concordant: normal heart anatomy.-Discordant: (corrected transposition).-Univentricular: hypoplastic left heart syndrome.4.Ventricles and the interventricular septum.5.Outflow tracts and ventriculoarterial connections.6.Great vessels. Z score: standard deviation above or below an age-specific group mean. This is useful in serial assessments of disease as a child grows. Normal is within 2 standard deviations. Ejection fraction. Fractional shortening. Left ventricular systolic performance. Tricuspid annular plane systolic excursion TAPSE: distance tricuspid annulus moves during systole. Fractional area change: “ejection fraction of the right ventricle.” Impression:1.Large interatrial communication in the canal portion of the atrial septum.2.Single AV junction.3.Unrestrictive interventricular communication in the canal portion of the ventricular septum.11Forshaw N. Broadhead M. Fenton M. How to interpret a paediatric echocardiography report.BJA Educ. 2020; 20: 278-286Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar,12Jegatheeswaran A. Pizarro C. Caldarone C.A. Cohen M.S. Baffa J.M. Gremmels D.B. et al.Echocardiographic definition and surgical decision-making in unbalanced atrioventricular septal defect.Circulation. 2010; 122: S209-S215Crossref PubMed Scopus (85) Google Scholar A complete atrioventricular septal defect (AVSD) is illustrated in Figure 2. The goal of medical management is to reestablish fetal blood circulation with an oxygen saturation goal of 75% to 85%. The approach varies based on the defect.2Javed F. Aleysae N.A. Al-Mahbosh A.Y. Zubani A.A. Atash A.M. Salem H.B. et al.Complications after surgical repair of congenital heart disease in infants. An experience from tertiary care center.J Saudi Heart Assoc. 2021; 33: 271-278Crossref PubMed Scopus (1) Google Scholar,13Marwali E.M. Heineking B. Haas N.A. Pre and postoperative management of pediatric patients with congenital heart diseases.Pediatr Neonatal Surg. 2017; 5: 91-123Google Scholar Obstruction and circulation are shown in Table 4.Table 4Obstruction and circulationLeft heart obstructionRelies on patent duct for systemic circulationHypoplastic left heart syndrome, critical aortic stenosis/coarctationRight heart obstructionRelies on patent duct for pulmonary circulationCritical pulmonary valve stenosis/atresia, severe tetralogy of Fallot, severe Ebstein anomalyParallel circulationRelies on duct for pulmonary and systemic circulationTransposition of the great arteriesApproach to ductal-dependent systemic circulation:1.Provide patency of ductus arteriosus with continuous prostaglandin E1 infusion2.Lower systemic vascular resistance-Reduce afterload with sodium nitroprusside infusion-Initiate milrinone and/or dobutamine3.Increase pulmonary vascular resistance-Avoid intubation; aim for mild metabolic acidosis and mild hypoventilationApproach to ductal-dependent pulmonic circulation1.Provide patency of ductus arteriosus with continuous prostaglandin E1 infusion2.Lower pulmonary vascular resistance-Aim for mild metabolic alkalosis, hyperventilation, and increase inspired oxygen fraction3.Increase systemic vascular resistance-Initiate norepinephrine or epinephrine-Increase volume status Open table in a new tab •What is the respiratory rate and are chest movements symmetrical? Check oxygen saturation and adjust ventilator settings. •Compare peripheral pulses. If there is an arterial line, check the central venous pressure, cardiac index, systolic blood pressure, pulmonary capillary wedge pressure. •What is their sedation? Check the size of the pupils. Are they spontaneously moving? •What is the chest tube output? Are they to suction or water seal? •Hyperthermia and hypothermia can be signs of sepsis. •Are they producing urine? Is a Foley in place? Does the color of the urine indicate acute kidney injury? What is the rate of fluid infusion? How are their electrolytes? •Note pacemaker settings. How many lines are there? Are there peripheral lines or central lines? Which side are the lines on? Important parameters in postoperative management and transfer to pediatric intensive care unit are listed in Table 5. Common postoperative complications and management are shown in Table 6.2Javed F. Aleysae N.A. Al-Mahbosh A.Y. Zubani A.A. Atash A.M. Salem H.B. et al.Complications after surgical repair of congenital heart disease in infants. An experience from tertiary care center.J Saudi Heart Assoc. 2021; 33: 271-278Crossref PubMed Scopus (1) Google Scholar,13Marwali E.M. Heineking B. Haas N.A. Pre and postoperative management of pediatric patients with congenital heart diseases.Pediatr Neonatal Surg. 2017; 5: 91-123Google ScholarTable 5Important parameters in postoperative management and transfer to PICUVentilator settingsRespiratory rates, breaths/minNeonates: 40Infants: 25-30Toddlers: 25Elementary school–aged children: 20Adolescents: 15Tidal volume: 6-8 mL/kgPEEP: 5-10 mm HgFIO2: pathology dependentVariants:Univentricular heart: target oxygen saturation 80%Fontan heart: PEEP <5 mm HgPulmonary HTN: Mild hyperventilation FIO2 level for O2 goal of 100%, PaO2 >150 mm HgHemodynamicsNormal rangeCardiac output, L/min Neonate/infant0.8-1.3 Child1.3-3.0Cardiac index, L/min/m2 Neonate/infant4.0-5.0 Child3.0-4.5Heart rate, beats/min Neonate/infant100-180 Pediatric70-110Stroke volume, mL/beat Neonate/infant5-13 Pediatric13-50Preload RAP/CVP, mm Hg Neonate/infant0-8 Pediatric2-6Right atrium, infant1 mm HgRight ventricle26/2 mm HgPulmonary artery, infant26/12 mm HgLeft atrium, infant3 mm HgLeft ventricle, infant60/3 mm HgAorta, infant70/50 mm HgPEEP, Positive end-expiratory pressure; FIO2, inspired oxygen fraction; HTN, hypertension; PaO2, arterial oxygen tension; RAP, right atrial pressure; CVP, central venous pressure; PICU, pediatric intensive care unit.2Javed F. Aleysae N.A. Al-Mahbosh A.Y. Zubani A.A. Atash A.M. Salem H.B. et al.Complications after surgical repair of congenital heart disease in infants. An experience from tertiary care center.J Saudi Heart Assoc. 2021; 33: 271-278Crossref PubMed Scopus (1) Google Scholar,13Marwali E.M. Heineking B. Haas N.A. Pre and postoperative management of pediatric patients with congenital heart diseases.Pediatr Neonatal Surg. 2017; 5: 91-123Google Scholar Open table in a new tab Table 6Common postoperative complications and managementLow cardiac output syndromeReplace volume, inotropes, afterload reduction (ie, sodium nitroprusside)Pulmonary hypertensive crisisAdminister O2, alkalosis, inhaled NO, hyperventilationTachyarrhythmias: beta-blockade, amiodarone, cardioversion if unstable Stable re-entrant tachycardiaVagal maneuvers, adenosine, or beta-blockers Unstable re-entrant tachycardiaAdenosine, synchronized cardioversion Ectopic atrial tachycardiaBeta-blockers (eg, esmolol) Junctional ectopic tachycardiaAmiodaroneBradyarrhythmia: pacing, atropine in the emergent setting Isolated sick sinus syndromeTemporary pacing wires with atrial pacing AV blockTemporary pacing wires with AV sequential pacingNO, Nitric oxide; AV, atrioventricular.2Javed F. Aleysae N.A. Al-Mahbosh A.Y. Zubani A.A. Atash A.M. Salem H.B. et al.Complications after surgical repair of congenital heart disease in infants. An experience from tertiary care center.J Saudi Heart Assoc. 2021; 33: 271-278Crossref PubMed Scopus (1) Google Scholar,13Marwali E.M. Heineking B. Haas N.A. Pre and postoperative management of pediatric patients with congenital heart diseases.Pediatr Neonatal Surg. 2017; 5: 91-123Google Scholar Open table in a new tab PEEP, Positive end-expiratory pressure; FIO2, inspired oxygen fraction; HTN, hypertension; PaO2, arterial oxygen tension; RAP, right atrial pressure; CVP, central venous pressure; PICU, pediatric intensive care unit.2Javed F. Aleysae N.A. Al-Mahbosh A.Y. Zubani A.A. Atash A.M. Salem H.B. et al.Complications after surgical repair of congenital heart disease in infants. An experience from tertiary care center.J Saudi Heart Assoc. 2021; 33: 271-278Crossref PubMed Scopus (1) Google Scholar,13Marwali E.M. Heineking B. Haas N.A. Pre and postoperative management of pediatric patients with congenital heart diseases.Pediatr Neonatal Surg. 2017; 5: 91-123Google Scholar NO, Nitric oxide; AV, atrioventricular.2Javed F. Aleysae N.A. Al-Mahbosh A.Y. Zubani A.A. Atash A.M. Salem H.B. et al.Complications after surgical repair of congenital heart disease in infants. An experience from tertiary care center.J Saudi Heart Assoc. 2021; 33: 271-278Crossref PubMed Scopus (1) Google Scholar,13Marwali E.M. Heineking B. Haas N.A. Pre and postoperative management of pediatric patients with congenital heart diseases.Pediatr Neonatal Surg. 2017; 5: 91-123Google Scholar •Diagnosis of the patient and corrective procedure.•Surgical techniques and any operative complications.•Drains and chest tube placement: suction/water seal.•Intraoperative echo findings.•Presence of intraoperative bleeding or arrhythmias and management.•Bypass time.•Crossclamp time.•Hypothermia use. The first 1 to 2 days is resuscitative due to losses in the operating room, vasoplegia from cardiopulmonary bypass (CPB), and capillary leak from CPB. Recommend bolus resuscitation with judicious product use as indicated by coagulopathy/anemia. After day 2 to 3, diuresis can be considered if patient is stable.1Mavroudis C. Backer C.L. Atlas of Pediatric Cardiac Surgery. Springer, 2015Crossref Google Scholar, 2Javed F. Aleysae N.A. Al-Mahbosh A.Y. Zubani A.A. Atash A.M. Salem H.B. et al.Complications after surgical repair of congenital heart disease in infants. An experience from tertiary care center.J Saudi Heart Assoc. 2021; 33: 271-278Crossref PubMed Scopus (1) Google Scholar, 3Kaiser L. Kron I.L. Spray T.L. Mastery of cardiothoracic surgery. Lippincott Williams & Wilkins, 2013Google Scholar,9Elsherif Z. Mahmood N. Jamil S. Wagas H. Complex congenital heart disease in a complicated and precious pregnancy.BMJ Case Rep. 2015; 2015bcr2015209388PubMed Google Scholar,13Marwali E.M. Heineking B. Haas N.A. Pre and postoperative management of pediatric patients with congenital heart diseases.Pediatr Neonatal Surg. 2017; 5: 91-123Google Scholar Low cardiac output syndrome is a common postoperative complication in patients who underwent procedures requiring CPB. The first step is to evaluate for residual anatomic lesions by echo or cardiac catheterization. Medical management involves milrinone, catecholamines, and pressors. If medical management is not sufficient, mechanical circulatory support is initiated with extracorporeal membrane oxygenation (ECMO) being the preferred method. In extreme cases, an expediated workup for pediatric heart transplant is possible but is complicated by time constraints and anatomical and immunological factors.1Mavroudis C. Backer C.L. Atlas of Pediatric Cardiac Surgery. Springer, 2015Crossref Google Scholar,2Javed F. Aleysae N.A. Al-Mahbosh A.Y. Zubani A.A. Atash A.M. Salem H.B. et al.Complications after surgical repair of congenital heart disease in infants. An experience from tertiary care center.J Saudi Heart Assoc. 2021; 33: 271-278Crossref PubMed Scopus (1) Google Scholar,9Elsherif Z. Mahmood N. Jamil S. Wagas H. Complex congenital heart disease in a complicated and precious pregnancy.BMJ Case Rep. 2015; 2015bcr2015209388PubMed Google Scholar,13Marwali E.M. Heineking B. Haas N.A. Pre and postoperative management of pediatric patients with congenital heart diseases.Pediatr Neonatal Surg. 2017; 5: 91-123Google Scholar Antibiotics are continued for 2 to 3 days. Patients on ECMO or with open sternotomies require antibiotics until 24 hours following decannulation and/or closure of sternotomy.1Mavroudis C. Backer C.L. Atlas of Pediatric Cardiac Surgery. Springer, 2015Crossref Google Scholar, 2Javed F. Aleysae N.A. Al-Mahbosh A.Y. Zubani A.A. Atash A.M. Salem H.B. et al.Complications after surgical repair of congenital heart disease in infants. An experience from tertiary care center.J Saudi Heart Assoc. 2021; 33: 271-278Crossref PubMed Scopus (1) Google Scholar, 3Kaiser L. Kron I.L. Spray T.L. Mastery of cardiothoracic surgery. Lippincott Williams & Wilkins, 2013Google Scholar,9Elsherif Z. Mahmood N. Jamil S. Wagas H. Complex congenital heart disease in a complicated and precious pregnancy.BMJ Case Rep. 2015; 2015bcr2015209388PubMed Google Scholar,13Marwali E.M. Heineking B. Haas N.A. Pre and postoperative management of pediatric patients with congenital heart diseases.Pediatr Neonatal Surg. 2017; 5: 91-123Google Scholar A continuous infusion of an opiate and benzodiazepine combination is used in the immediate postoperative period. Pain is then managed with a multimodal regimen, minimizing opiate use to only what is necessary for 2 to 3 days following surgery.1Mavroudis C. Backer C.L. Atlas of Pediatric Cardiac Surgery. Springer, 2015Crossref Google Scholar, 2Javed F. Aleysae N.A. Al-Mahbosh A.Y. Zubani A.A. Atash A.M. Salem H.B. et al.Complications after surgical repair of congenital heart disease in infants. An experience from tertiary care center.J Saudi Heart Assoc. 2021; 33: 271-278Crossref PubMed Scopus (1) Google Scholar, 3Kaiser L. Kron I.L. Spray T.L. Mastery of cardiothoracic surgery. Lippincott Williams & Wilkins, 2013Google Scholar,9Elsherif Z. Mahmood N. Jamil S. Wagas H. Complex congenital heart disease in a complicated and precious pregnancy.BMJ Case Rep. 2015; 2015bcr2015209388PubMed Google Scholar,13Marwali E.M. Heineking B. Haas N.A. Pre and postoperative management of pediatric patients with congenital heart diseases.Pediatr Neonatal Surg. 2017; 5: 91-123Google Scholar CBP can lead to renal impairment, and acute kidney injury is very common after cardiac surgery. Urine excretion of at least 2 mL/kg/h after cardiac surgery is the minimum to ensure adequate fluid balance. In addition, loop diuretics are administered after the resuscitative phase.1Mavroudis C. Backer C.L. Atlas of Pediatric Cardiac Surgery. Springer, 2015Crossref Google Scholar, 2Javed F. Aleysae N.A. Al-Mahbosh A.Y. Zubani A.A. Atash A.M. Salem H.B. et al.Complications after surgical repair of congenital heart disease in infants. An experience from tertiary care center.J Saudi Heart Assoc. 2021; 33: 271-278Crossref PubMed Scopus (1) Google Scholar, 3Kaiser L. Kron I.L. Spray T.L. Mastery of cardiothoracic surgery. Lippincott Williams & Wilkins, 2013Google Scholar,9Elsherif Z. Mahmood N. Jamil S. Wagas H. Complex congenital heart disease in a complicated and precious pregnancy.BMJ Case Rep. 2015; 2015bcr2015209388PubMed Google Scholar,13Marwali E.M. Heineking B. Haas N.A. Pre and postoperative management of pediatric patients with congenital heart diseases.Pediatr Neonatal Surg. 2017; 5: 91-123Google Scholar The ductus arteriosus is a normal part of fetal circulation that arises from the distal portion of the sixth and eighth embryonic aortic arch. In a PDA, the communication remains patent between the systemic and pulmonary vasculature. The most common location of a PDA is between the isthmus of the distal aortic arch and the origin of the left pulmonary artery.1Mavroudis C. Backer C.L. Atlas of Pediatric Cardiac Surgery. Springer, 2015Crossref Google Scholar,3Kaiser L. Kron I.L. Spray T.L. Mastery of cardiothoracic surgery. Lippincott Williams & Wilkins, 2013Google Scholar,13Marwali E.M. Heineking B. Haas N.A. Pre and postoperative management of pediatric patients with congenital heart diseases.Pediatr Neonatal Surg. 2017; 5: 91-123Google Scholar,14Dice J.E. Bhatia J. Patent ductus arteriosus: an overview.J Pediatr Pharmacol Ther. 2007; 12: 138-446PubMed Google Scholar Small PDA-Asymptomatic.Large PDA-Failure to thrive.-Heaving laterally displaced apical pulse (left ventricular volume overload).-Wide pulse pressure with bounding pulses.-Loud continuous machinery murmur heard best at the left infraclavicular region.-Symptoms of pulmonary overcirculation, feeding intolerance, dyspnea. Initial management includes COX inhibitors, with indomethacin being the preferre