Cardiopulmonary Bypass in Neonatal Cardiac Surgery

A significant advantage of these crystalloid solutions is their ability to flush all residual blood out of the heart chambers and provide an extended window of myocardial protection, potentially lasting up to ninety minutes or two hours between doses. This allows the surgical team to work for longer periods without the interruptions required for re-administering the solution. Administration of the solution can occur through different routes depending on the patient's anatomy and the specific surgical requirements. The most common method in pediatric cardiac surgery is anterograde delivery, where the solution is injected into the ascending aorta to perfuse the coronary arteries in the natural direction of flow. In some complex cases, particularly in adult surgery, a retrograde approach may be used by cannulating the coronary sinus and delivering the solution in reverse. Regardless of the route, the solution is typically delivered very cold, often at 10 degrees Celsius or lower, to provide additional protection to the myocardium by reducing its metabolic and energy requirements. These solutions also contain components that assist with energy production after the cross-clamp is removed, ensuring the heart has an adequate energy source for recovery. While cardioplegia is essential for the surgical repair, it introduces physiological challenges that the perfusionist must actively manage. Because crystalloid solutions are often low in sodium and calcium, they can disrupt the patient's electrolyte balance as they mix with the circulating blood in the reservoir. This imbalance, if left uncorrected, can lead to complications such as tissue edema. At the conclusion of the intra-cardiac repair, the team begins the process of de-airing the heart and rewarming the patient. Once the heart is closed and the air is removed, the aortic cross-clamp is released, allowing warm, oxygenated blood to reperfuse the myocardium. This reperfusion washes out the cardioplegic solution and restores the heart's electrolyte balance, which usually results in a spontaneous return of the heart's rhythm without the need for significant mechanical stimulation.

Hypothermia

In pediatric cardiac surgery, hypothermia is a foundational technique used to protect the patient's vital organs and the heart itself by significantly reducing metabolic demand and oxygen consumption during complex repairs. This process is managed by the perfusionist through a heat exchanger integrated into the cardiopulmonary bypass circuit, allowing for precise control of the patient's blood temperature. While some surgeries are performed under normothermia (maintaining a temperature of 36–37°C), many cases require cooling to mitigate the risks associated with prolonged operative times or the need for reduced blood flow. The degree of cooling is tailored to the complexity of the surgical procedure. Deep hypothermia, typically defined between 18°C and 24°C, is reserved for the most intricate repairs, such as aortic arch reconstructions or the Norwood procedure. At these extremely low temperatures, surgeons can safely employ deep hypothermic circulatory arrest (DHCA), where the heart-lung machine is stopped entirely to provide a motionless, bloodless field without damaging the brain or other organs. Alternatively, deep hypothermia may be paired with selective cerebral perfusion, where oxygenated blood is directed specifically to the head vessels while the rest of the body's circulation is paused. Beyond organ protection, cooling the patient allows the perfusionist to reduce the overall pump flow rate, which helps prevent the surgical field from being "flooded" with blood, thereby improving the surgeon's visibility during delicate intracardiac work. Despite its protective benefits, hypothermia introduces several clinical challenges and trade-offs. One primary downside is the increased duration of the procedure, as cooling and rewarming the patient are gradual processes that add significant time to the bypass run. Furthermore, hypothermia is known to interfere with the body's coagulation system, often leading to increased post-operative bleeding compared to normothermic procedures. Because of these risks, some modern programs have shifted toward a hybrid approach, utilizing high-flow bypass at more moderate temperatures—typically not going lower than 30°C—to reduce bypass times and minimize bleeding complications. The management of temperature continues into the transition from the operating room to the intensive care unit. As the surgical repair concludes, the perfusionist begins rewarming the patient by circulating warm blood through the heat exchanger. However, patients who have been cooled dramatically often experience a secondary dip in temperature once they reach the ICU. Even if they appear normothermic upon leaving the operating room, their temperature can drop to as low as 33°C shortly after arrival, a trend that intensivists must monitor closely to ensure hemodynamic stability and proper recovery.

Bypass and cross-clamping

A critical component of the bypass phase is the application of the aortic cross-clamp, which is necessary for any repair requiring access to the interior of the heart or the aortic arch. The clamp is placed proximal to the aortic cannula to prevent air from shunting from the right side of the heart to the left, where it could be ejected into the cerebral vessels. Once the clamp is applied, the heart is isolated and receives the cold cardioplegic solution while the rest of the body is perfused by the pump. Because these crystalloid solutions can be low in sodium and calcium, they often mix with the circulating blood and can disrupt electrolyte balance, which the perfusionist must monitor and correct to prevent issues like tissue edema.

Role of the Cardiac Intensivist and Congenital Cardiologist in OR and Cardiac Intensive Care Unit

The congenital cardiologist and/or neonatal or pediatric cardiac intensivists have an essential role in the perioperative care of children undergoing cardiac surgery. This role extends beyond diagnosis and preoperative planning; it includes guidance of (pre-, peri- and post-interventional) hemodynamic management, antenatal counselling and management, intraoperative assessment, immediate evaluation of surgical repair, recognition of residual lesions, and ongoing support in the cardiac intensive care unit. Because congenital heart surgery modifies anatomy and physiology in real time, the cardiac expert must understand both the surgical sequence and the postoperative physiological consequences of repair or palliation.

Cardiac surgery begins with meticulous preparation. After arrival in the operating room, the patient is placed on continuous monitoring and undergoes anesthetic induction and endotracheal intubation. In congenital heart disease, induction must be adapted to the patient’s underlying physiology. For example, a patient with excessive pulmonary blood flow should not necessarily receive prolonged preoxygenation with 100% oxygen, as this may further reduce pulmonary vascular resistance, increase pulmonary overcirculation, and compromise systemic output. This illustrates the importance of specialized pediatric cardiac anesthesia, as even apparently routine anesthetic interventions can significantly alter the balance between systemic and pulmonary circulation. Invasive monitoring is then established. Most children undergoing open-heart surgery will receive an arterial catheter for continuous blood pressure monitoring and a central venous catheter for administration of vasoactive medications and assessment of filling pressures. Femoral access is often preferred when preservation of jugular veins is desirable. Antibiotic prophylaxis is administered, and additional medications may include corticosteroids or agents targeting hemostasis, depending on institutional practice and surgical context. The patient is positioned according to the operative approach: supine for median sternotomy or lateral decubitus for thoracotomy.

Once the surgical field is prepared, the surgeon proceeds with incision and sternotomy, followed by preparation for cardiopulmonary bypass. Heparin is administered before cannulation. Cardiopulmonary bypass is initiated only when adequate anticoagulation has been achieved and the circuit can provide the required systemic flow. Ventilation is discontinued (or tapered) only once the bypass circuit provides full theoretical flow. At that stage, the heart may be arrested using cardioplegia, allowing the surgeon to operate on a still and bloodless field while myocardial protection is maintained.

Several intraoperative variables are important for the postoperative team to know. The duration of cardiopulmonary bypass, the aortic cross-clamp time, the type and adequacy of cardioplegia, and any intraoperative concerns regarding coronary perfusion or myocardial protection all influence postoperative cardiac function. These details are particularly important when the postoperative course is marked by unexplained ventricular dysfunction or hemodynamic instability. After completion of the intracardiac or vascular repair, the aortic clamp is removed and the team observes the return of electrical activity and mechanical contraction. Manual ventilation is resumed, followed by mechanical ventilation. Inotropic support is adjusted according to ventricular recovery and systemic perfusion. This is the point at which the congenital cardiologist most commonly becomes involved intraoperatively. Transesophageal echocardiography is used to assess deairing, ventricular function, residual lesions, valve competence, outflow obstruction, and regional wall motion. The information provided by the cardiologist helps the surgical team determine whether the repair is acceptable or whether the patient should return to cardiopulmonary bypass for further correction.

In neonates and small infants, delayed sternal closure may be required after complex surgery. This strategy is used when immediate closure would compromise ventilation or hemodynamics because of myocardial edema, pulmonary edema, capillary leak, or the inflammatory effects of cardiopulmonary bypass. The chest is temporarily covered with a sterile dressing, allowing time for stabilization before definitive closure, often after 24 to 48 hours or longer if instability persists. Although most open-heart procedures require cardiopulmonary bypass, some cardiac operations may be performed without it. These include selected pacemaker insertions, some repairs of coarctation of the aorta, and closure of a patent ductus arteriosus. However, procedures requiring opening of the heart or prolonged intracardiac exposure generally require cardiopulmonary bypass to ensure systemic perfusion and provide the surgeon with adequate visualization.

Intraoperative Transesophageal Echocardiography

Transesophageal echocardiography is a central tool in intraoperative congenital cardiology. Probe selection depends on patient size, with neonatal, pediatric, and adult probes available. The examination differs from transthoracic echocardiography because the probe lies posterior to the heart within the esophagus or stomach. The operator can advance or withdraw the probe, rotate it clockwise or counterclockwise, change the imaging angle from 0 to 180 degrees, and flex the tip anteriorly or posteriorly. These maneuvers allow comprehensive imaging of cardiac structures from multiple planes. Contraindications to transesophageal echocardiography must be respected, particularly in neonates and infants. Esophageal atresia, esophageal stenosis, prior esophageal surgery, significant esophageal injury, mediastinal malformations, severe cervical pathology, or marked hemodynamic or respiratory instability may preclude or limit the examination. Complications are uncommon but include transient dysphagia, minor gastrointestinal injury, accidental extubation during probe manipulation, thermal injury, and rarely esophageal perforation. Because neonatal tissues are fragile and probes may generate heat, transesophageal echocardiography in neonates should be performed only when the expected benefit justifies the risk. Transesophageal echocardiography is particularly valuable for valve surgery, assessment of atrial and ventricular septal defects, evaluation of residual shunts, assessment of outflow tracts, and detection of regional wall motion abnormalities after coronary manipulation. In valvular disease, it provides high-resolution imaging of valve morphology and allows the cardiologist to describe the mechanism of regurgitation or stenosis in terms meaningful to the surgeon. During or after repair, it is used to determine whether the residual lesion is acceptable or whether revision is needed.

• Several standard views are especially useful. High esophageal views allow assessment of the great arteries and pulmonary arteries. 

• Mid-esophageal views include the four-chamber view, the short-axis view at the level of the aortic valve, and long-axis views of the left ventricular outflow tract. 

• Transgastric views provide short-axis images of the ventricles and are particularly useful for assessing global and regional ventricular function. 

• Deep transgastric views align the ultrasound beam with the left ventricular outflow tract and aortic valve, permitting more accurate Doppler assessment of gradients.

• The atrial septum is examined using mid-esophageal four-chamber and bicaval views. These views are sensitive for residual atrial septal defects and for abnormalities of systemic venous return. After surgical closure, the cardiologist confirms the absence of residual interatrial shunting and ensures that systemic or pulmonary venous pathways are not obstructed. Because transesophageal color Doppler orientation differs from transthoracic imaging, the direction of color flow must be interpreted carefully.

• The ventricular septum is assessed using four-chamber and transgastric short-axis views. Residual ventricular septal defects are common targets of intraoperative assessment. A small restrictive residual defect at the patch margin may be accepted if hemodynamically insignificant, whereas a larger defect may require return to bypass for closure.

• Transesophageal echocardiography also provides immediate assessment of global ventricular function and identifies regional wall motion abnormalities. Segmental dysfunction is particularly important after procedures involving coronary manipulation, such as arterial switch operations or coronary reimplantation. A new regional wall motion abnormality may indicate coronary obstruction, kinking, or injury and may require immediate surgical correction.

• The aortic valve is well visualized by transesophageal echocardiography. Short-axis imaging at approximately 45 degrees allows identification of the right coronary, left coronary, and noncoronary cusps using anatomic landmarks. This is useful in bicuspid aortic valve repair, commissurotomy, or aortic valvuloplasty, where the surgeon needs a precise description of commissural fusion, raphe location, cusp mobility, and the mechanism of stenosis or regurgitation. Long-axis views assess the left ventricular outflow tract, aortic annulus, sinuses, sinotubular junction, and ascending aorta. Deep transgastric views are particularly useful for measuring residual gradients after intervention.

• The mitral valve also requires detailed segmental analysis. The cardiologist should describe the lesion rather than merely quantify regurgitation. Important features include prolapse, restriction, cleft, leaflet thickening, chordal abnormalities, annular dilation, commissural involvement, and the specific scallops involved. Transgastric short-axis and bicommissural views allow systematic assessment of the anterior and posterior leaflets. After repair, residual mitral regurgitation is evaluated according to severity, mechanism, and location, allowing the team to decide whether the result is acceptable.

The Cardiac Intensive Care Unit

After surgery, care continues seamlessly in the cardiac intensive care unit. The postoperative handover should include the diagnosis, surgical procedure, bypass and cross-clamp times, intraoperative complications, cardioplegia details, residual lesions, ventricular function, rhythm issues, bleeding, vasoactive support, ventilation strategy, and any concerns regarding pulmonary vascular resistance or coronary perfusion. The cardiologist, cardiac anesthetist and cardiac intensive care expert contribute to the interpretation of postoperative physiology, recognizing that loading conditions, vasoactive medications, ventilation, sedation, and evolving inflammation may significantly change the echocardiographic appearance within hours. The immediate postoperative assessment includes clinical examination, invasive blood pressure, central venous pressure, oxygen saturation, electrocardiography, chest radiography, blood gas analysis, lactate measurement, coagulation studies, drain output, and echocardiography. Echocardiography evaluates the surgical result, residual lesions, ventricular function, regional wall motion, pulmonary pressures, filling pressures, and pericardial or pleural effusions. Particular attention must be paid to tamponade. A blocked mediastinal drain in a bleeding postoperative patient can rapidly cause life-threatening cardiac compression, requiring urgent intervention.

Early extubation is an important marker of an uncomplicated postoperative course and may improve cardiopulmonary interactions. Positive pressure ventilation increases intrathoracic pressure and may impair venous return or cavopulmonary flow, particularly after right-sided procedures such as bidirectional cavopulmonary anastomosis. In selected patients, extubation can improve pulmonary blood flow and systemic output. However, extubation must be individualized according to respiratory status, hemodynamics, bleeding, neurologic status, and the complexity of the repair.

Postoperative Ventricular Dysfunction and Low Cardiac Output

• Left ventricular dysfunction after cardiac surgery may present with tachycardia, hypotension, rising lactate, elevated left atrial pressure, pulmonary edema, and reduced systemic perfusion. Echocardiography typically shows reduced systolic function and may demonstrate left ventricular dilation. Potential causes include prolonged cross-clamp time, inadequate myocardial protection, coronary injury, residual obstruction, residual shunt, tamponade, or unrecognized left-sided obstruction such as coarctation. Management aims to optimize heart rate, preload, afterload, contractility, and oxygen delivery. Temporary atrial pacing may be useful in neonates, whose cardiac output is highly heart-rate dependent. Inotropes such as epinephrine and inodilators such as milrinone are commonly used, with careful attention to their different effects on systemic vascular resistance. Fluid administration should be cautious, particularly when left atrial pressure is elevated.

• Right ventricular dysfunction is common after surgery involving the right ventricular outflow tract, pulmonary arteries, tetralogy of Fallot, truncus arteriosus, or other right-sided lesions. Clinical features include hepatomegaly, elevated central venous pressure, low cardiac output, pleural effusions, ascites, and prolonged drainage. Large effusions are not benign; they may cause protein loss, immunoglobulin loss, nutritional compromise, and increased infection risk. Echocardiography demonstrates right ventricular dilation and impaired contraction. Management includes optimization of preload, diuresis, inotropic support, reduction of pulmonary vascular resistance using oxygen, inhaled nitric oxide, ventilation strategies, and milrinone, and, when needed, augmentation of systemic vascular resistance to improve right-to-left shunt physiology.

• Pulmonary hypertensive crises are a major postoperative concern, particularly after cardiopulmonary bypass. Clinically, they may occur during agitation or light anesthesia and can lead to abrupt desaturation, low cardiac output, bradycardia, and arrest. Echocardiography may show elevated right-sided pressures, right ventricular dilation, septal shift, and underfilling of the left ventricle. Acute management includes deepening sedation, ensuring adequate oxygenation, correcting acidosis, avoiding hypothermia, optimizing ventilation, excluding reversible triggers such as atelectasis or pneumothorax, and administering inhaled nitric oxide. Oxygen is itself a potent pulmonary vasodilator, and inhaled nitric oxide is most rational when adequate oxygen delivery is ensured.

Management of Shunt Physiology

Many postoperative patients, especially those with single-ventricle physiology, require careful balancing of pulmonary and systemic blood flow. The objective is not simply to normalize oxygen saturation, but to optimize systemic oxygen delivery. Excessive pulmonary blood flow may produce attractive saturations while causing systemic hypoperfusion and coronary steal. Conversely, inadequate pulmonary blood flow may cause hypoxemia and acidosis. The clinician must therefore interpret saturation in the context of perfusion, lactate, venous saturation, blood pressure, urine output, echocardiography, and acid-base status. Pulmonary blood flow can be "manipulated" by attempting changes in pulmonary vascular resistance, systemic vascular resistance, ventilation, oxygen concentration, carbon dioxide, pH, sedation, temperature, and hemoglobin concentration. In patients with pulmonary overcirculation, reducing inspired oxygen, accepting moderate hypercarbia when appropriate, increasing pulmonary vascular resistance, increasing blood viscosity, or reducing systemic vasodilation may help restore balance. In patients with inadequate pulmonary blood flow, improving oxygenation, correcting acidosis, reducing pulmonary vascular resistance, maintaining preload, and ensuring shunt patency are key. In single-ventricle physiology, a target saturation around 80 to 85% often suggests a more balanced Qp:Qs, but the ideal target depends on the lesion, stage of palliation, and clinical context.

Extracorporeal Membrane Oxygenation (See full section on Neonatal ECMO)

Extracorporeal membrane oxygenation provides temporary circulatory and respiratory support when the heart cannot maintain adequate systemic perfusion despite maximal medical therapy. In the postoperative congenital cardiac setting, the goal is often myocardial recovery. The circuit consists of drainage and return cannulas, a pump, an oxygenator, and tubing. In small infants, the circuit volume is clinically important because it may represent a large proportion of the patient’s blood volume; priming with blood is often required to avoid profound hemodilution. Postoperative indications include severe myocardial dysfunction, coronary insufficiency, failure to separate from cardiopulmonary bypass, severe low cardiac output, residual lesions pending correction, post-transplant graft dysfunction, and selected arrhythmia-related or cardiomyopathic presentations. ECMO should be initiated only when there is a realistic therapeutic objective: myocardial recovery, surgical correction, bridge to transplant, or another defined endpoint. Severe uncontrolled bleeding, irreversible neurologic injury, or absence of a viable plan may represent contraindications. Cannulation may be central or peripheral. Central cannulation provides excellent flow and may allow left heart decompression, particularly in patients whose chest is already open after surgery. Peripheral cannulation may involve the carotid and jugular vessels in neonates or femoral vessels in larger patients. Congenital heart disease adds specific complexity. Systemic-to-pulmonary shunts may cause excessive pulmonary runoff during venoarterial ECMO, resulting in systemic hypoperfusion; partial shunt restriction may be necessary. Abnormal systemic or pulmonary venous anatomy may also influence cannulation strategy. ECMO complications include bleeding, thrombosis, neurologic injury, infection, and mechanical failure. Bleeding is common because anticoagulation is required in patients who may already be at high postoperative bleeding risk. Thrombosis may occur within the circuit, during low-flow states, during weaning, or inside a poorly ejecting ventricle. Maintaining some arterial pulsatility is important because a non-ejecting left ventricle may dilate and form intracardiac thrombus. Neurological complications, including ischemic and hemorrhagic injury, are among the most feared adverse events and have major implications for survival and neurodevelopment. Neuromonitoring with amplitude-integrated electroencephalography, electroencephalography, and near-infrared spectroscopy is therefore central to care.

Rhythm Disturbances and Temporary Pacing

Temporary epicardial pacing wires are commonly placed during congenital heart surgery. They provide an important safety mechanism in the postoperative period and allow the team to support cardiac output by increasing heart rate, restoring atrioventricular synchrony, or treating conduction disturbances. 

• Pacing modes are described by 

  • A) The chamber paced (A or V)

  • B) the chamber sensed

  • C) the response to sensing. 

• Atrial pacing modes such as AAI or AOO are frequently used when atrioventricular conduction is intact and the goal is to increase heart rate. 

• VVI pacing may be used when atrial rhythm is unreliable. 

• DOO provides asynchronous dual-chamber pacing and may be useful in emergencies. 

• DDD pacing senses and paces both chambers and can maintain atrioventricular synchrony.

When setting a temporary pacemaker, the team determines the pacing rate, output, sensitivity, and atrioventricular delay when dual-chamber pacing is used. The capture threshold is identified by gradually increasing output until consistent capture occurs; the output is then set above threshold, often approximately twice the threshold, to ensure reliable stimulation. 

• Postoperative arrhythmias may occur after any cardiac surgery, even after apparently simple procedures. Electrolyte disturbances are frequent after bypass, diuretics, and parenteral nutrition, so potassium, calcium, and magnesium should be checked and corrected. Supraventricular tachycardia may be treated by correcting electrolytes, administering magnesium, overdrive pacing through temporary atrial wires, synchronized cardioversion if unstable, and antiarrhythmic therapy such as intravenous amiodarone when recurrent or poorly tolerated. Atrial electrograms recorded through pacing wires can help distinguish atrial from ventricular rhythms when surface electrocardiography is unclear.

• Junctional ectopic tachycardia is a common postoperative arrhythmia and may mimic ventricular tachycardia. Management includes correction of electrolytes, temperature control, reduction of catecholamine stimulation when possible, optimization of sedation, atrial pacing strategies, and antiarrhythmic therapy when necessary. 

• Ventricular fibrillation is treated as cardiac arrest, with high-quality resuscitation, defibrillation, epinephrine, and amiodarone according to resuscitation algorithms, while the cardiology team rapidly searches for reversible causes such as coronary obstruction, shunt thrombosis, tamponade, or severe ventricular dysfunction.

• Conduction disturbances are also common after congenital heart surgery. Right bundle branch block is frequent and often benign, particularly after ventricular septal defect closure or right ventricular surgery. Complete atrioventricular block is more concerning, especially after operations close to the conduction tissue, such as atrioventricular septal defect repair, ventricular septal defect closure, and surgery in patients with congenitally abnormal conduction pathways. Postoperative complete heart block may recover, often within the first 10 days. Temporary pacing is used while awaiting recovery, and permanent pacemaker implantation is generally considered if high-grade block persists beyond the expected recovery window.

Lesion-Specific Surgical Considerations

For systemic-to-pulmonary shunts such as a modified Blalock-Taussig-Thomas shunt, postoperative physiology can be difficult to balance. The shunt must be large enough to provide pulmonary blood flow but not so large that it causes pulmonary overcirculation and systemic or coronary steal. Excessive oxygen administration or aggressive ventilation may reduce pulmonary vascular resistance and worsen pulmonary runoff, whereas elevated pulmonary vascular resistance may reduce shunt flow and increase the risk of thrombosis. Acute desaturation after shunt surgery should raise concern for shunt thrombosis, requiring immediate heparin administration and urgent surgical evaluation. In coarctation of the aorta, the preoperative echocardiogram should describe the entire aortic arch anatomy, the severity and length of narrowing, associated arch hypoplasia, and associated left-sided lesions such as bicuspid aortic valve, subaortic stenosis, supravalvar aortic stenosis, or mitral abnormalities. Severe coarctation may compromise mesenteric perfusion, and feeding must be approached cautiously because of the risk of intestinal ischemia and necrotizing enterocolitis. Postoperatively, hypertension and residual arch obstruction must be carefully monitored.

For ventricular septal defects, the surgeon requires a precise anatomic description. The report should define the number of defects, location, relationship to valves and conduction tissue, size, shunt direction, hemodynamic significance, and associated lesions. The surgical approach may differ depending on whether the defect is perimembranous, muscular, inlet, outlet, apical, anterior, or posterior. Postoperative imaging must assess for residual shunting, ventricular function, valve regurgitation, and outflow obstruction.

In tetralogy of Fallot, the preoperative echocardiogram should describe the pulmonary annulus, right ventricular outflow tract, pulmonary valve, main and branch pulmonary arteries, number and location of ventricular septal defects, and any additional levels of right-sided obstruction. Coronary anatomy is critical, particularly the presence of a coronary artery crossing the right ventricular outflow tract, which may alter the surgical strategy. Postoperative concerns include right ventricular dysfunction, residual right ventricular outflow obstruction, pulmonary regurgitation, branch pulmonary artery stenosis, and residual ventricular septal defect.

In transposition of the great arteries, the arterial switch operation requires careful preoperative definition of coronary anatomy. The presence of a single coronary ostium, intramural coronary course, anterior or posterior looping, or abnormal commissural alignment increases surgical complexity. The report should also describe ventricular septal defects, outflow tract obstruction, semilunar valve regurgitation, annular discrepancy, and possible coarctation. Postoperatively, assessment must focus on ventricular function, regional wall motion abnormalities suggesting coronary compromise, neopulmonary or neoaortic valve function, branch pulmonary artery stenosis, residual arch obstruction, and pulmonary hypertension. A calm recovery is important, as these patients may develop significant left ventricular dysfunction, particularly when the preoperative left ventricle was deconditioned or ischemic.

Conclusion

The congenital cardiologist and cardiac intensive care expert play a pivotal role throughout the perioperative pathway of pediatric cardiac surgery. In the operating room, transesophageal echocardiography provides immediate anatomic and functional information that may determine whether a repair is accepted or revised. In the cardiac intensive care unit, the cardiologist helps interpret complex and rapidly changing physiology, guides management of ventricular dysfunction, pulmonary hypertension, shunt balance, arrhythmias, and residual lesions, and identifies patients who may require mechanical circulatory support. Accurate, anatomically detailed echocardiographic reporting is essential, because the more precisely the cardiologist describes the lesion, the better the surgical team can plan and execute the repair.

References