Invited commentary

Abstract

Congenital heart surgeons are acutely aware of the interaction between the heart and the pulmonary circulation. These constitute both anatomic and physiologic relationships. Problems with the pulmonary arterial tree are myriad, and abnormal pulmonary venous return is an area with which congenital surgeons are quite comfortable. Some of the most difficult problems in the correction of congenital heart disease relate to the pulmonary microcirculation and pulmonary hypertension. Fewer congenital heart surgeons are facile with the interaction between the airway system and the heart. The physiologic effects of airway obstruction can, as demonstrated by the authors, be very dramatic and life threatening in the recovery of children with well repaired congenital cardiovascular anomalies. Recognition and avoidance of these problems depends on a keen awareness of the anatomy of the airway system, and its relationship to cardiac anatomy. The passage of the left mainstem bronchus under the aortic arch can be problematic in direct repair of interruption of the aortic arch. Aortas carrying flow destined for the lungs, such as patients with shunts or collaterals can enlarge and compromise the area the trachea must traverse anterior to the spine.One of the difficulties with assessing any anatomic problem, and determining its impact, is the ability to develop a quantitative method of describing the effect. The authors have created such a method of evaluating the problem, and have implied that this could be used to determine who is at risk and who might benefit from therapeutic intervention. In this case the procedure used was aortopexy, although other forms of airway intervention, such as stenting, may also prove useful. It is incumbent on congenital heart surgeons to incorporate these tools into the armamentarium of treatment of congenital heart disease. This must be done, first, by increased awareness of the possibility that an unexpected post operative course may relate to extrinsic airway compression or distortion. Secondly, methods such as those described here must be adapted to guide the surgical team in selecting patients and interventions to improve respiratory function when airway impairment occurs. And finally, these same methods and others must be used to determine if the selected interventions accomplish their desired purpose. Congenital heart surgeons are acutely aware of the interaction between the heart and the pulmonary circulation. These constitute both anatomic and physiologic relationships. Problems with the pulmonary arterial tree are myriad, and abnormal pulmonary venous return is an area with which congenital surgeons are quite comfortable. Some of the most difficult problems in the correction of congenital heart disease relate to the pulmonary microcirculation and pulmonary hypertension. Fewer congenital heart surgeons are facile with the interaction between the airway system and the heart. The physiologic effects of airway obstruction can, as demonstrated by the authors, be very dramatic and life threatening in the recovery of children with well repaired congenital cardiovascular anomalies. Recognition and avoidance of these problems depends on a keen awareness of the anatomy of the airway system, and its relationship to cardiac anatomy. The passage of the left mainstem bronchus under the aortic arch can be problematic in direct repair of interruption of the aortic arch. Aortas carrying flow destined for the lungs, such as patients with shunts or collaterals can enlarge and compromise the area the trachea must traverse anterior to the spine. One of the difficulties with assessing any anatomic problem, and determining its impact, is the ability to develop a quantitative method of describing the effect. The authors have created such a method of evaluating the problem, and have implied that this could be used to determine who is at risk and who might benefit from therapeutic intervention. In this case the procedure used was aortopexy, although other forms of airway intervention, such as stenting, may also prove useful. It is incumbent on congenital heart surgeons to incorporate these tools into the armamentarium of treatment of congenital heart disease. This must be done, first, by increased awareness of the possibility that an unexpected post operative course may relate to extrinsic airway compression or distortion. Secondly, methods such as those described here must be adapted to guide the surgical team in selecting patients and interventions to improve respiratory function when airway impairment occurs. And finally, these same methods and others must be used to determine if the selected interventions accomplish their desired purpose.