Paediatric Heart Surgery (ASD/VSD Closure)

Overview

If you are reading this for your son or daughter, you have probably heard a doctor say there is a "hole in the heart". Those words are hard to hear. Many of these holes can be closed, often by a procedure through a vein, and many children who have them repaired grow up to lead active lives, with regular check-ups along the way.

Congenital heart disease means a heart problem a child is born with. The most common are holes in the walls that divide the heart's chambers:

• ASD (atrial septal defect): a hole between the two upper chambers.
• VSD (ventricular septal defect): a hole between the two lower chambers.
• PDA (patent ductus arteriosus): a blood vessel that should close after birth but stays open.

These let extra blood flow into the lungs. Over time, this can strain the heart and raise the pressure in the lungs. Other conditions repaired in childhood include tetralogy of Fallot, a combination of four problems that can make a child look blue, and coarctation, a narrowing of the main artery leaving the heart.

Who needs it

Not every hole needs closing. Small VSDs and some small ASDs close on their own in the first years of life, and the cardiologist may simply watch them with regular scans. Closure is usually advised when:

• the child breathes fast, sweats while feeding, tires easily or gains weight slowly
• there are frequent chest infections
• the echocardiogram shows the heart is enlarged or working too hard
• the lung pressure is rising
• the defect is a type that will not close by itself

Timing matters. If a large hole is left too long, the blood vessels in the lungs can be damaged in a way that cannot be reversed, and closure may no longer be safe. That is why we ask for your child's most recent echocardiogram, an ultrasound scan of the heart, with the first message. Paediatric cardiologists review it, and several partner hospitals then quote for the treatment they would recommend. You can name the country you would prefer, or ask hospitals in more than one country to quote. You compare and choose.

How it is done

There are two main ways to close a defect. Which one suits your child depends on the type of hole, its size and position, and the child's weight.

Device closure through a catheter

Many ASDs and PDAs, and some VSDs, can be closed without opening the chest. Under general anaesthesia, the cardiologist passes a thin tube through a vein at the top of the leg up to the heart. Guided by X-ray and ultrasound, they place a small folding device that opens on both sides of the hole like a double umbrella and plugs it. Heart tissue grows over the device in the months that follow. The procedure usually takes one to two hours. Most children go home within one to two days.

Open heart surgery

Larger holes, holes in difficult positions, and more complex repairs such as tetralogy of Fallot need surgery. The surgeon opens the chest, usually through the breastbone, and a heart-lung machine takes over the circulation while the heart is stopped. The hole is closed with stitches or a patch. These operations commonly take three to five hours, and the surgeon will give you a clearer estimate.

Before either procedure

Expect one or two days of checks after arrival. These include an echocardiogram, an ECG (a tracing of the heart's electrical activity), a chest X-ray, blood tests, the child's weight and height, and a check for any infection. Some children also need a CT or MRI scan, or a cardiac catheterisation to measure the pressure in the lungs. An anaesthetist will meet you to explain how your child will be put to sleep and when they must stop eating and drinking.

Recovery and how long you stay

After device closure, your child usually spends the night on the ward with a parent. They may need to lie still for a few hours to protect the groin puncture. An echocardiogram the next day checks the device position. Children are often given aspirin for about six months while the device heals in, and antibiotics before dental treatment during that time. Plan for about 10 days in total in the country where you are treated.

After open surgery, your child goes to the paediatric intensive care unit (PICU). For the first day or two you will see a breathing tube, drips, chest drains and many monitors. Parents can usually visit the PICU, though each hospital sets its own times. The breathing tube often comes out within the first day. Most children move to the ward after one to three days and leave hospital about seven to ten days after the operation. Plan for about three weeks in the destination country, so the surgeon can check the wound and repeat the echocardiogram before clearing your child to fly.

For about six weeks after chest surgery, surgeons usually advise lifting your child with a hand under the bottom and behind the back, not under the arms. Your child's own surgeon will give you the exact limits. Expect tiredness and some poor appetite at first. Many children are playing again before their parents are ready for it.

MediCurage coordinates and the hospital team treats your child. When the PICU lets only one parent stay overnight, the other needs a room a short walk or drive away, and that is the first thing we look for when we book your stay.

Questions to ask your surgeon

• Exactly which defect does my child have, and can it be closed with a device?
• Why is now the right time, and what happens if we wait?
• What will the PICU stay involve, and when can I be with my child?
• Will my child need medicines after going home, and for how long?
• Is a second operation or procedure likely as my child grows?
• How often will my child need echocardiograms at home, and who can do them?

Before you leave, ask for a short letter for your child's school or nursery that says what was done and when running games and sport can start again. Teachers tend to follow a doctor's note more readily than a parent's description, and it saves your child being kept out of play for longer than needed.