From
StayCurrentMD
QUAD #21: Management of Concurrent Cardiac Pathologies with Dr. David Lehenbauer
With Dr. David Lehenbauer · hosted by Dr. Em Gootee
Chapter 1 of 6 · Fundamentals
Introduction
Introduction and Context
Expert statements on this page
No expert statements were drawn from this page.
Host summaries · secondary, not cited in answers
Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
More about this diagnosis
Complete tracheal ringsPodcast
Vascular Rings with Dr. Carl Backer
19 min · Published Sep 2023
Video
QUAD #16 - Flexible Bronchoscopy in Management of Slide Tracheoplasty Patients - Sara Zak
CCHMC Pediatric Surgery · 9 min · Published Oct 2024
Video
TEF Presentations (Extended): Aerodigestive & Esophageal Surgery
108 min · Published Dec 2014
Video
QUAD #6 Slide Tracheoplasty for TEF, Otolaryngology Approach with Dr. Mike Rutter
CCHMC Pediatric Surgery · 7 min · Published Mar 2024
Video
Laryngotracheal Stenosis
CCHMC Pediatric Surgery · 16 min · Published May 2022
Video
Intestinal Atresia Types Explained: Grossfeld Classification for Pediatric Surgery
1 min · Published Sep 2026
Video
Derivation and validation of the Pediatric Community-Acquired Pneumonia Severity (PedCAPS) score: A prospective cohort study
50 s · Published Sep 2026
Video
FETO for Late-Diagnosed Severe Congenital Diaphragmatic Hernia (CDH) at Cincinnati Children's with Dr. Beth Rymeski
4 min · Published Sep 2026
Video
Severe Congenital Diaphragmatic Hernia (CDH) Case: FETO Management & Unexpected Findings with Dr. Beth Rymeski
3 min · Published Sep 2026
Video
Fetoscopic Endoluminal Tracheal Occlusion (FETO) Procedure: Step-by-Step Guide with Dr. Beth Rymeski
4 min · Published Sep 2026
Video
Choledochal Cyst Types Explained: Pediatric Surgery Fundamentals
1 min · Published Sep 2026
What the experts said
At Cincinnati Children's, almost all operative interventions for tracheal stenosis are slide tracheoplasty.
Slide tracheoplasty was introduced by Sank in the late 1980s and popularized by Hermes Gillo in the 1990s.
The main difference between bypass and ECMO is the venous reservoir; bypass includes pump suckers and vents useful for open heart repairs, while ECMO consists essentially of an oxygenator and pump.
At Cincinnati, unless doing concurrent cardiac repairs, ECMO circuit is preferred over full bypass.
For ECMO during slide tracheoplasty, Cincinnati loads with only 100 units of heparin per kilogram with a much lower activated clotting time goal.
ECMO is cheaper than full bypass, the patient remains pulsatile (which has been shown to be advantageous), the pump is smaller allowing room for bronchoscopy, and there is less blood-air interaction reducing inflammation.
In rare cases needing postoperative ECMO, using ECMO intraoperatively conserves another circuit.
The main problem with ECMO is incomplete cardiac decompression, resulting in more cardiac volume in the surgical field, though blood volume can be removed if needed.
A major concern with ECMO is that if air is entrained, there is no way to evacuate it other than turning the pump off, whereas the venous circuit in bypass tolerates air well.
Full cardiopulmonary bypass provides complete cardiac decompression, allows the heart to be moved out of the way, can deal with air, and permits use of pump suckers, though pump suckers are not advantageous for slide tracheoplasty due to tracheal secretions.
Extrapolating from adult lung transplant data, ECMO is associated with significantly less bleeding, renal failure, need for tracheostomy, blood transfusions, shorter ventilation time, and shorter hospital stay compared to bypass.
Full bypass is required for open heart repairs and redo slide tracheoplasties, with a pump at least available during redo sternotomy due to risk of major bleeding.
During redo operations, hilar releases are performed by starting in the pleural spaces, finding the inferior pulmonary ligament, mobilizing up to the pulmonary veins and pericardium around the inferior vein to reduce tension for tracheal reconstruction.
Even in the modern era, slide tracheoplasty for congenital tracheal stenosis has significant morbidity and mortality.
A recent Japanese study found a 25% risk of infectious complications after slide tracheoplasty.
Most modern series report slide tracheoplasty mortality between 5% and 30%.
Known risk factors for mortality include operating on children less than one month of age, children with a single lung, and associated cardiac disease.
A Japanese study with 80 patients over 22 years found that complex cardiovascular anomalies and preoperative ECMO were risk factors for mortality.
The Society of Thoracic Surgeons database survey found over 2,000 operations, with over 400 combined airway and cardiac operations.
Patients undergoing tracheal intervention concurrent with cardiac operation had significant risk for morbidity and mortality.
The most common associated cardiac lesion with tracheal stenosis is the pulmonary artery sling.
Other associated cardiac lesions include ASDs, VSDs, tetralogy of Fallot, PDAs, and vascular rings.
Almost all PA slings can be fixed concurrently during tracheal repair.
PA sling repair involves reimplantation, which most of the time happens much closer to the main pulmonary artery, usually at the insertion of the ligamentum, rather than back where it was harvested.
Controversy exists regarding appropriate timing: fixing cardiac lesions first puts the child at risk from residual tracheal pathology; fixing trachea first means healing occurs with impaired circulation and possible hypoxemia; staggering approaches results in multiple redo operations.
The role for palliation in complex tracheal and cardiac disease is undefined.
From a cardiac surgery perspective, there has been a great increase in patients managed with ductal stenting and stenting of pulmonary arteries, but literature is unclear about palliation of cardiac disease with concurrent tracheal pathology.
A Japanese paper advocated simultaneous reconstruction for simple cardiac disease and staged approach for complex heart disease, with overall low mortality.
The Great Ormond Street series had overall very low mortality and did not find cardiac disease to be a significant risk factor for mortality.
Great Ormond Street found that preoperative ECMO, tracheomalacia, and bronchial stenosis were risk factors for mortality.
Great Ormond Street advocates for combined repair based on their experience.
In the modern era, single-stage or combined repair is preferred.
PA slings, ASDs, VSDs, PDAs, and vascular rings are straightforward simple disease that should be manageable concurrently with slide tracheoplasty.
Tetralogy of Fallot is a spectrum: basic cases are straightforward to manage with simple repairs, while very complex patients' treatment is driven by specific comorbidities and complexity of both cardiac and tracheal disease.
A big drawback of full bypass is that much more heparin is given, the blood is thinner, and a much higher ACT is targeted to reduce clotting through cardiotomy suckers and venous reservoir.
At Cincinnati Children's, all patients are pre-operatively tested for organisms and treated with appropriate antibiotics.