1. Congenital heart disease comprises a wide morphologic
spectrum. In general, lesions can be conceptualized as those which
can be completely repaired, those that should be palliated, and
those that can be either repaired or palliated depending on particular patient
and institutional characteristics.
2. Percutaneous therapies for congenital heart disease are quickly
becoming important adjuncts, and in some cases, alternatives, to
standard surgical therapy. Important examples include percutaneous
closure of atrial and ventricular septal defects, the hybrid approach
to hypoplastic left heart syndrome, radiofrequency perforation of
the pulmonary valve, and percutaneous pulmonary valve placement.
Further studies are necessary to establish criteria and current
benchmarks for the safe integration of these novel approaches into
the care of patients with congenital heart surgery.
3. Outcomes have improved substantially over time in congenital
heart surgery, and most complex lesions can be operated in early
infancy. Neurologic protection, however, remains a key issue in
the care of neonates undergoing surgery with cardiopulmonary bypass
and deep hypothermic circulatory arrest. New monitoring devices
and perioperative strategies are currently under investigation.
Attention in the field has shifted currently from analyses of perioperative
mortality, which for most lesions is under 10%, to longer-term
outcomes, including quality of life and neurologic function.
Congenital heart surgery is a constantly evolving field. The
last 20 years have brought about rapid developments in the technologic realm
as well as a more thorough understanding of both the anatomy and
pathophysiology of congenital heart disease (CHD), leading to the
improved care of patients with this challenging disease.1,2
These new advancements created a paradigm shift in the field
of pediatric heart surgery. The traditional strategy of initial
palliation followed by definitive correction at a later age, which
had pervaded the thinking of most surgeons, began to evolve to one
emphasizing early repair, even in the tiniest patients.2 Furthermore,
some of the defects that were virtually uniformly fatal [such
as hypoplastic left-heart syndrome (HLHS)] now can be successfully
treated with aggressive forms of palliation using cardiopulmonary
bypass (CPB), resulting in outstanding survival for many of these
Because the goal in most cases of CHD is now early repair, as opposed
to subdividing lesions into cyanotic or noncyanotic lesions, a more
appropriate classification scheme divides particular defects into
three categories based on the feasibility of achieving this goal:
(a) defects that have no reasonable palliation and for which repair
is the only option; (b) defects for which repair is not possible and
for which palliation is the only option; and (c) defects that can either
be repaired or palliated in infancy.3 It bears
mentioning that all defects in the second category are those in
which the appropriate anatomic components either are not present,
as in HLHS, or cannot be created from existing structures.
An atrial septal defect (ASD) is defined as an opening ...