Objective To investigate the impact of three kinds of palliative operation on the body and growth of pulmonary artery in patients with congenital heart diseases of diminutive pulmonary blood. Methods Clinical data was reviewed in 28 cases of congenital heart diseases with diminutive pulmonary blood who had been performed cavopulmonary connection （n = 9）, systemic-pulmonary shunt （n = 8 ）, and palliative reconstruction of right ventricular outflow tract （n=11）. The period between re-hospitalized and the first was 5-54 months （19.07±10. 06 months ）. Hematocrit （HCT）, hemoglobin （Hb）, percutaneous oxygen saturation （SpO2）, body surface area （BSA）, and pulmonary artery index （PAI） etc. were observed both before palliation and before the second operation. Results After the second hospitalization, there were 7 cases of death from hemorrhage, failure of circulation and extracorporeal circulation accident etc. The time of respirator, intensive care unit and total amount of dopamine in patients of palliative reconstruction of right ventricular outflow tract were longer and more than those in patients of cavopulmonary connection （P〈0. 05）. HCT, Hb before the second operation were decreased than thoes before palliative operations in all patients, SpO2, BSA and PAI increased significantly （P 〈 0. 01 ）. Before the second operation, BSA of patients with cavopulmonary connection, BSA and PAI of patients with systemic-pulmonary shunt, SpO2, BSA and PAI of patients with palliative reconstruction of right ventricular outflow tract were increased than those before palliative operations（P〈0. 01）. HCT of palliative reconstruction of right ventricular outflow tract was decreased（P〈0. 05）. Conclusion This results suggests that pulmonary blood of patients with congenital heart diseases of diminutive pulmonary blood can be increased, development of pulmonary arteries can be improved efficiently by systemic-pulmonary shunt and palliative reconstruction of right ventricle outflow tract, but it can not be found in cavopulmonary connection patients.
ObjectiveTo review the experience of the surgical treatment of child patients with anomalous left coronary artery from the pulmonary artery (ALCAPA). MethodsWe retrospectively analyzed the clinical data of 56 children patients with ALCAPA underwent coronary re-implantation in our hospital from April 2004 through February 2015. There were 35 males and 21 females at mean age of 25.5 (7.3-60.0) months. Nineteen patients (33.9%) were less than 1 year of age. The mean weight was 11.8 (7.8-19.8) kg. ResultsThere was one death in-hospital. The mean cardiopulmonary bypass time and cross-clamp time was 131.8± 61.2 min and 83.4± 32.1min, respectively. The mean mechanical ventilation time and intensive care unit time was 12.5 (6.5-43.8) h and 49.0 (21.0-116.0) h, respectively. Three patients underwent extracorporeal membrane oxygenation (ECMO) support and weaned off successfully. The mean postoperative left ventricular ejection fraction (LVEF, 63.4%± 15.8% vs. 50.6%± 18.7%) and left ventricular end diastolic diameter (LVEDD, 36.4± 32.5 mm vs. 42.3± 7.4 mm) significantly improved compared postoperative (P < 0.05). The mitral regurgitation (MR) distribution in the 15 patients underwent mitral valve repair was:moderate in 2 patients, mild in 8 patients, trivial in 2 patients and none in 3 patients. The MR in the other 41 patients improved or did not change. The survivors completed the follow-up for a mean time of 45.4± 23.6 months. During the follow-up period, one patient died due to noncardiac reason. No patient required reoperation or readmission. All the patients survived with New York Heart Association heart function classⅠor classⅡ. At the latest echocardiography, the mean LVEF (62.8%± 5.0%) significantly improved compared with the LVEF of discharge. The MR distribution was moderate in 6 patients, mild in 24 patients, trivial in 4 patients and none in 21 patients. ConclusionThe coronary re-implantation has a satisfactory mid-term result for patients with ALCAPA. Mitral valve repair is recommended for the patients with severe regurgitation and evident ischemic lesions of the papillary muscles.
ObjectiveTo compare early clinical outcomes between systemic-pulmonary shunts (SPS) and right ventricular to pulmonary artery connection (RV-PA connection) for patients with pulmonary atresia and ventricular septal defect (PA/VSD), and investigate early management strategies for these 2 different palliative procedures. MethodsWe retrospectively analyzed clinical data of 89 PA/VSD patients who underwent SPS or RV-PA connection in Fu Wai Hospital from January 2009 to December 2011. According to different surgical procedures, all the 89 patients were divided into 2 groups. In SPS group, there were 59 patients including 35 males and 24 females with their median age of 25 months (4 months to 8 years). In RV-PA connection group, there were 30 patients including 19 males and 11 females with their median age of 24 months (28 days to 7 years and 2 months). Early clinical outcomes including mechanical ventilation time, length of ICU stay, morbidity, reexploration, improvement of oxygen saturation (SO2) and mortality were compared between the 2 groups. ResultsAmong 59 patients in SPS group, 3 patients (5.1%) died postoperatively. There was no in-hospital death among 30 patients in RV-PA connection group. The improvement of percentage of SO2 of RV-PA connection group was significantly higher than that of SPS group (31.7% vs. 22.2%, P < 0.05). There was no statistical difference in length of ICU stay (3.6±2.5 days vs. 4.2±5.1 days, P > 0.05), mechanical ventilation time (34.8±33.5 hours vs. 44.3±39.6 hours, P > 0.05), postoperative morbidity (37.3% vs. 30.0%, P > 0.05) or reexploration rate (15.3% vs. 6.7%, P > 0.05) between SPS group and RV-PA connection group. Incidence of serious postoperative complications of SPS group was signi-ficantly higher than that of RV-PA connection group (25.4% vs. 6.7%, P < 0.05). ConclusionEarly clinical outcomes of RV-PA connection is better than SPS for PA/VSD patients including greater SO2 improvement and lower mortality. Mid-term and long-term clinical results as well as larger study samples are needed for better evaluation.
Objective To assess clinical results of three different conduit materials （Gore-Tex synthetic graft，bovinejugular vein and autologous pericardium）for palliative right ventricle-to-pulmonary artery （RV-PA） shunt，and explore the correlation between suitable conduit size and patients’ body weight and McGoon ratio. Methods We retrospectively analyzed clinical data of 24 patients with congenital heart diseases who underwent palliative RV-PA shunt in Department of Pediatric Cardiovascular Surgery of Fu Wai Cardiovascular Hospital from July 2010 to July 2012. There were 11 males and 13 females with their age ranging from 60 days to 6 years and body weight of 10.22±7.41 kg. There were 22 patients with pulmonary atresia and ventricular septal defect （PAVSD），1 patient with tetralogy of Fallot （TOF） and 1 patient with doubleoutlet right ventricle （DORV）. Among different conduit materials，autologous pericardium was used for 17 patients，Gore-Texsynthetic graft was used for 5 patients，and bovine jugular vein was used for 2 patients. Conduit size and children’s body weight were analyzed with linear regression，then the equation was corrected with McGoon ratio. Results There was no perioperative death. Postoperative percutaneous saturation （SpO2）of the 24 children was 20.37%±28.33% higher than preoperative SpO2 . Electrocardiogram showed sinus rhythm in all the patients. Twenty-three patients were NYHA classⅡ，and 1 patient was NYHA classⅢ. Postoperative mechanical ventilation time of patients with autologous pericardium were significantly shorter than those of patients with other 2 materials （P=0.017）. Sixteen patients were followed up from 10 months to 2 years after discharge，including 12 patients with autologous pericardium，3 patients with Gore-Tex synthetic graft and 1 patient with bovine jugular vein. During follow-up，McGoon ratio of patients with autologous pericardium，Gore-Tex synthetic graft and bovine jugular vein were 1.98±0.46，1.83±0.33 and 1.68 respectively，all of which weresignificantly higher than preoperative McGoon ratio （P＜0.05）. Six patients underwent radical corrective surgery，including5 patients with autologous pericardium and 1 patient with Gore-Tex synthetic graft. There was no complication directly related to surgery during follow-up. Linear regression was performed to form an equation between suitable conduit size and patients’ body weight：conduit diameter （mm）=0.327×body weight （kg）＋4.599. McGoon ratio，conduit size and equationresult were compared to find a practical choice of conduit size. If McGoon ratio＜0.8，the first integer greater than the equation result could be chosen. If McGoon ratio＞1.2，the first integer less than the equation result could be chosen. If 1.2＞McGoon ratio＞0.8，the first integer either less or greater than the equation result could be chosen. Group analysis showed that patients who recovered better postoperatively were those whose conduit sizes were closer to equation results as well as equation results corrected with McGoon ratio. Conclusion All the 3 materials can be conventionally chosen for RV-PA shunt. Appropriate conduit size can be decided upon patients’ body weight and McGoon ratio for RV-PA shunt.
Abstract： Objective To summarize our experience of surgical treatment for anomalous origin of one pulmonary artery in infants and children. Methods From March 2005 to May 2010，11 patients with anomalous origin of one pulmonary artery and other concomitant congenital cardiovascular malformations underwent surgical repair in Xijing Hospital of Fourth Military Medical University．The mean age of the patients was 11.5 months with a range from 2 months to 36 months．Their mean body weight was 7.1 kg with a range from 4 to 13 kg. Seven patients had anomalous origin of the right pulmonary artery from the ascending aorta, and four patients had anomalous origin of the left pulmonary artery from the ascending aorta. All the eleven patients had other concomitant intracardiac anomalies or vascular malformations as well as pulmonary hypertension, and underwent one stage surgical repair via median sternotomy under hypothermia and cardiopulmonary bypass. Results Their operation time was 169 - 293 （231±55） min, cardiopulmonary bypass time was 87-210 （138±47） min, and aortic-clamping time was 45-133 （86±28） min. There was one postoperative death who had low cardiac output syndrome after repair for tetralogy of Fallot and anomalous origin of the right pulmonary artery. The overall postoperative mortality was 9.1％. Postoperative echocardiography of all the surviving patients showed their left and right pulmonary artery origined from the right ventricle and pulmonary artery with satisfactory malformation correction but no residual shunt and pulmonary stenosis . All the surviving ten patients were followed up with a follow-up rate of 100% and mean follow-up time of 13.5 months with a range from 3 to 32 months. Their echocardiography during follow-up showed that there was no pulmonary stenosis in all the patients, and pulmonary blood pressure significantly decreased in 9 patients. Conclusion Patients with anomalous origin of one pulmonary artery should undergo surgical repair as early as possible with satisfactory short-term outcomes in infants and children. For elder patients with irreversible pulmonary hypertension, the choice of surgical treatment should be more cautious. During the surgery, the anomalous pulmonary artery and ascending aorta should be dissociated fully, and transection of the ascending aorta is helpful to get a satisfactory operating field view for the surgeon. Repairing aortic defect with autologous pulmonary arterial patch can effectively avoid the occurrence of postoperative aortic aneurysm.
ObjectiveTo compare and investigate the efficacy and differences of modified B-T shunt, central shunt and right ventricle-pulmonary artery (RV-PA) connection in the treatment of pulmonary atresia with ventricular septal defect (PA/VSD).MethodsA total of 124 children with PA/VSD underwent initial palliative repair in Shanghai Children's Medical Center from September 2014 to August 2019, including 63 males and 61 females, aged 7 days to 15 years. They were divided into in a modified B-T shunt group (55 patients), a central shunt group (22 patients) and a RV-PA connection group (47 patients). The clinical data of these children were retrospectively analyzed.ResultsThere were 9 early deaths after palliation, with an early mortality rate of 7.3%. The mean follow-up time was 26.5±20.3 months, with 5 patients lost to follow-up, 5 deaths during the follow-up period, and 105 survivors. The 1-year and 5-year survival rates were both 89.7%. The monthly increased Nakata index was 5.2 (–0.2, 12.3) mm2/m2, 9.2 (0.1, 23.6) mm2/m2, 6.3 (1.8, 23.3) mm2/m2 in the modified B-T shunt group, the central shunt group, and the RV-PA connection group, respectively, with no statistical difference among the three groups. The 1-year survival rate was 85.3%, 78.4%, 95.2%, and the 5-year (4-year in the central shunt group) survival rate was 85.3%, 58.8%, 95.2% in the three groups, respectively, with a statistical difference among them (P<0.05). The complete repair rate was 36.5%, 19.0% and 67.4% in the three groups, respectively, with a statistical difference among the three groups (P<0.001).ConclusionAll these three palliative surgical approaches can effectively promote pulmonary vascular development. But compared with systemic-pulmonary shunt, RV-PA connection has a lower perioperative mortality rate and can achieve a higher complete repair rate at a later stage, which is beneficial for long-term prognosis.
ObjectiveTo analyze the early outcomes of anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) patients with severe left ventricular dysfunction after surgical repair, and to explore the predictors for extracorporeal membrane oxygenation (ECMO) support for these patients.MethodsThe clinical data of ALCAPA patients with severe left ventricular dysfunction (left ventricular ejection fraction<40%) who underwent coronary artery reimplantation in the pediatric center of our hospital from 2013 to 2020 were retrospectively analyzed. The patients were divided into an ECMO group and a non-ECMO group. Clinical data of the two groups were compared and analyzed.ResultsA total of 64 ALCAPA patients were included. There were 7 patients in the ECMO group, including 4 males and 3 females aged 6.58±1.84 months. There were 57 pateints in the non-ECMO group, including 30 males and 27 females aged 4.34±2.56 months. The mortality of the patients was 6.25% (4/64), including 2 patients in the ECMO group, and 2 in the non-ECMO group. The postoperative complications rate was significantly higher in the ECMO group than that in the non-ECMO group (P=0.041). There were statistical differences in the cardiopulmonary bypass time [254 (153, 417) min vs. 106 (51, 192) min, P=0.013], aortic cross-clamping (ACC) time (89.57±13.66 min vs. 61.58±19.57 min, P=0.039), and preoperative left ventricular end-diastolic diameter/body surface area (132.32±14.71 mm/m2 vs. 108.00±29.64 mm/m2, P=0.040) between the two groups. Multivariate logistic regression analysis showed that ACC time was an independent risk factor for postoperative ECMO support (P=0.005). Receiver operating characteristic (ROC) curve analysis showed that the area under the ROC curve was 0.757, the sensitivity was 85.70%, specificity was 66.70%, with the cut-off value of 66 min.ConclusionACC time is an independent risk factor for postoperative ECMO support. Patients with an ACC time>66 min have a significantly higher risk for ECMO support after the surgery.
ObjectiveIn order to correct left pulmonary artery (LPA) stenosis in tetralogy of Fallot (TOF), a technique for LPA reconstruction by widening pulmonary arterial posterior wall was devised. To evaluate its surgical technique as well as postoperative outcome. MethodsFrom January 2008 through August 2014 year, 1 142 consecutive patients underwent repair of TOF including 44 patients with TOF and LPA stenosis in our hospital. We used widening pulmonary arterial posterior wall for LPA reconstruction in 21 patients. The median age was 22.8 months (range, 1 month to 11 years), and the median weight was 9.1 kg (range, 3.8-29 kg). ResultsThere was one operative death. No death occurred during the follow-up period in the other 20 patients. There were 4 patients with complicate unbalanced pulmonary perfusion postoperatively. Echocardiography at 3-72 months follow-up demonstrated no obvious stenosis was found at LPA in 14 patients, and mild stenosis (32.8±12.7 mm Hg) in 6 patients. Only 1 patient required further interventions because of restenosis of LPA. ConclusionsLPA reconstruction by widening pulmonary arterial posterior wall is an effective method in the management of stenosis of LPA in the patients with TOF. We emphasize division of the arterial duct or ligamentum completely because it will tether and kink the LPA. This procedure retains the better growth potential by increasing autogenous tissue of native tissue.
ObjectiveTo explore surgical methods and risk factors of anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA). MethodsClinical data of 28 ALCAPA patients who underwent surgical repair from October 1993 to September 2013 in Beijing Anzhen Hospital were retrospectively reviewed. There were 8 male and 20 female patients with their age of 0.6-l6.8 (4.3±0.7)years including 10 patients less than 1 years old. Surgical procedures included simple ligation of left coronary artery, intrapulmonary tunnel procedure (Takeuchi)and direct coronary reimplantation of the anomalous artery. Postoperative death, complication and cardiac function were observed. ResultsAmong the 28 patients, 1 patient received simple ligation of left coronary artery, and 7 patients received intrapulmonary tunnel procedure (Takeuchi), among whom 2 patients died postoperatively. Twenty patients received direct implantation of the anomalous artery into the ascending aorta, and 3 patients died postoperatively. Five patients who died postoperatively were 10.20±3.27 months old, including 3 patients with moderate mitral regurgitation (MR)and 2 patients with mild MR preoperatively. Preoperative heart function of the patients who died postoperatively was significantly reduced. Preoperative left ventricular ejection fraction of the patients who died postoperatively was significantly lower than that of the patients who survived (36.6%±8.5% vs. 60.9%±10.7%, P=0.000). Low cardiac output syndrome was the reason for all postoperative death. All survival patients were followed up from 1 month to 18 years. One patient who underwent intra-pulmonary tunnel procedure (Takeuchi)received pulmonary artery balloon dilatation for pulmonary supravalvular stenosis 15 years after discharge. None of the other patients received a secondary operation. During follow-up, left ventricular function was improved. Growth and development of all the patients was normal. MR did not significantly aggravate in all the patients. ConclusionPatients with younger age and worse left ventricular function have greater surgical risks of ALCAPA.
Objective To analyze the clinical efficacy and mid-term outcomes of reimplantation of anomalous origin of left coronary artery from the pulmonary artery (ALCAPA), and to evaluate whether concomitant management of mitral regurgitation (MR) during ALCAPA repair is needed. Methods Between March 2005 and March 2015, 52 consecutive patients (20 males and 32 females with a median age of 10 months ranging 2-193 months) underwent reimplantation of ALCAPA at Department of Cardiac Surgery, Guangdong Cardiovascular Institute. There were 14 males and 21 females with a mean age of 35.4±42.8 months not receiving mitral valvuloplasty (a Non-MVP group), and 6 males and 11 females with a mean age of 13.5±11.0 months receiving mitral valvuloplasty (a MVP group). In order to facilitate the analysis, degree of MR was graded by number: 0.0=none, 1.0=trivial, 2.0=mild, 2.5=mild-moderate, 3.0=moderate, 3.5=moderate-severe and 4.0=severe. Results The left ventricular fractional shortening (LVFS) and left ventricular end diastolic diameter (LVEDD) demonstrated significant improvement between preoperation and discharge (28.6%±9.6% vs. 32.1%±10.1%, P=0.023; 38.4±5.6 mm vs. 30.5±5.7 mm, P<0.001), and there was also significant improvement in the mean MR grade between preoperation and discharge (2.9±1.2,vs. 2.4±1.2, P=0.001). There were 4 in-hospital deaths (7.7%). The median follow-up was 21.0 months (ranging 1.5-111.0 months). Three patients (5.8%) were lost to follow-up, 1 patient required reoperation for mitral valve replacement and there was no death during follow-up. Significant improvement was seen in LVFS between discharge and final follow-up (32.1%±10.1% vs. 38.0%±6.0%, P=0.001); however, there was no significant difference in the degree of MR between discharge and final follow-up (2.4±1.2 vs. 2.3±1.2, P=0.541). There was no significant difference in cardiopulmonary bypass time, aortic cross-clamping time, mechanical ventilation time or hospital stay between the two groups. Conclusion Creation of a dual coronary system with reimplantation of the left coronary artery results in complete recovery of left ventricular function. However, concomitant management of MR during ALCAPA repair remains controversial. Concomitant mitral valve repair for ALCAPA patients with moderate-severe and severe MR is helpful to early function recovery of mitral valve.