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Clinical study of ventilator-associated pneumonia in children after surgical correction for tetralogy of Fallot

ObjectiveTo investigate the incidence, pathogens, risk factors and clinical outcomes for ventilator- associated pneumonia (VAP) in children after tetralogy of Fallot (TOF) surgical correction, in order to offer reliable data for the prevention of VAP.MethodsThis was a retrospective study performed in Guangdong General Hospital and 181 children (121 males, 60 females, mean age of 11.2±10.4 months) undergoing surgical correction for TOF were included. ALL the children who received mechanical ventilation for 48 hours or longer between January 2013 and December 2017 were classified into a VAP group (n=44) and a non-VAP group (n=137). T test, χ2 test and multiple logistic regression analysis were used to identify the possible risk factors for VAP.ResultsThis study enrolled 181 patients , of which 44 were diagnosed as VAP. And the incidence of VAP was 24.3%. The most frequent isolated pathogen was Gram-negative bacteria (69.7%). Single factor analysis showed that the variables significantly associated with a risk factor of VAP were: hypoxic spells, preoperative pneumonia, preoperative mechanical ventilation support, cardiopulmonary bypass (CPB) time, reintubation, pulmonary atelectasis, low cardiac output syndrome (LCOS), intra-abdominal drainage and transfusion of fresh frozen plasma. The multiple logistic regression showed CPB time (OR=1.011), reintubation (OR=14.548), pulmonary atelectasis (OR=6.139) and LCOS (OR=3.054) were independent risk factors for VAP in children after TOF surgical correction. Patients with VAP had prolonged duration of mechanical ventilation, a longer ICU stay and longer hospitalization time.ConclusionsThe VAP rate in this population is higher than that reported abroad, which leads to prolonged duration of mechanical ventilation and a longer hospital stay. The effective measures for prevention of VAP should be taken according to the related risk factors for VAP to decrease the incidence of VAP in children after TOF surgical correction.

法洛四联症患者围手术期凝血功能变化及意义

目的 探讨法洛四联症（TOF）患者围术期凝血功能变化及临床意义，以减少术后血液系统并发症的发生。 方法 将2005年1月至2008年8月我院收治的65例接受外科手术治疗的TOF患者纳入研究（实验组），选择同期手术的65例非紫绀型先天性心脏病患者作为对照（对照组）。检测两组患者术前及手术后1周的血气、血常规、血浆凝血酶原时间（PT）、活化部分凝血活酶时间（APTT）、血浆Ⅷ和Ⅸ因子活性，并对各项指标术前、术后变化情况进行分析。 结果 组内比较：术后7 d实验组血红蛋白（Hb)和APTT均低于术前，动脉血氧分压(PaO2)、凝血因子Ⅷ和凝血因子Ⅸ均高于术前，PT变化不明显。组间比较：实验组术前Hb和APTT均高于对照组,PaO2、凝血因子Ⅷ和凝血因子Ⅸ均低于对照组（Plt;0.01）。 结论 TOF患者术前存在内源性凝血功能障碍，可能是自身凝血功能代偿以降低高粘血症带来的血栓形成危险，术后能得到改善，可能与血氧分压提高有关。

法洛四联症矫治术中自体心包梯形补片加宽右心室流出道35例

Surgical Treatment of Tetralogy of Fallot in 75 Adults

Abstract: Objective To evaluate the results of surgical treatment of tetralogy of Fallot in adults． Methods From July 2002 to August 2009，75 adult patients with tetralogy of Fallot received surgical treatment in Xijing Hospital, ForthMilitary Medical University．There were 35 males and 40 females, with age at l7 to 37 years (23.30±3.50 years), and eoperativehemoglobin at 143 to 231 g/L(172.00±31.00 g/L)．All these patients were diagnosed by.echocardiograph before operation. All the patients were received tetralogy of Fallot of corrective operation in the hypothermia cardiopulmonary bypass. A total of 46 patients had a transannular right ventricular outflow tract patch，and 29 patients had a non ansannular patch． Results Operation time was 157 to 276 min(221.32±41.34 min), cardiopulmonary bypass time was 68 to 163 min(91.71±28.35 min) and aorta intercepted time was 37 to 96 min（55.47±23.61 min）. There were 6 operative deaths with an operative mortality at 8.00％. The causes of death were low output syndrome(n=3)，acute renal failure(n=2)， and multiple organ failure(n=1)．Nine patients needed reoperation for postoperative bleeding(12.00％)．We followed up 69 patients from 3 to 56 months (26.31±7.40 months). There were 2 patients with trivial residual shunt. The cardiac function status were New York Heart Association(NYHA) Ⅰ to Ⅱ in the 69 patients．No late death occured． Conclusion The effectiveness of surgical treatment for adults with tetralogy of Fallot is satisfactory．

Cardiopulmonary Bypass Management of the Tetralogy of Fallot in Adults: a Report of 112 Cases

目的探讨成人法洛四联症（tetralogy of fallot，TOf）的体外循环（cardiaopulmonary bypass，CPB）管理策略。 方法回顾性分析2008年1月至2012年12月广东省人民医院收治TOf患者112例的临床资料，其中男51例、女61例，年龄17～49（26.8±11.3）岁。2例行右心室流出道疏通术，余为TOf根治术。CPB降温至中度或深度低温、采用中至低流量灌注。通过CPB开始时放自体血、加大预充液量等调整CPB中红细胞压积（HCT）维持在0.25至术前水平的1/2，持续给予6-氨基己酸、超滤、使用血液回收机等综合措施进行血液保护。心肌保护采用冷高钾含血或晶体心脏停搏液间断灌注，同时运用开放前温血灌注、术野充弥CO2辅助心腔排气等措施提高心肌保护效果。调控CPB中血氧分压，以术前氧分压水平开始CPB、逐渐增加到150 mm Hg左右，并维持至CPB血流复温再进一步升高，以减少全身各组织器官的再氧合损伤。 结果CPB时间60～272（127.5±31.5）min，主动脉阻断时间22～146（78.3±20.4）min，住ICU时间19～1 465（96.9±19.0）h，住院时间12～84（26.2±1.4）d。二次开胸止血12例，胸腔积液9例，急性肾功衰竭2例，乳糜胸2例；死亡4例，其中术后重度低心排血量综合征3例、多器官功能衰竭1例，住院死亡率3.6%。 结论成人TOf的CPB需要特别关注血液保护、心肌保护及减少再氧合损伤，以降低并发症、提高手术效果。

完全性房室间隔缺损合并法洛四联症外科矫治的单中心临床经验

目的分析单个临床中心完全性房室间隔缺损合并法洛四联症的外科治疗经验。方法回顾性分析广东省人民医院心外科 2008 年 5 月至 2017 年 3 月收治的 21 例经超声心动图诊断为完全性房室间隔缺损合并法洛四联症患者的外科矫治经验，其中男 17 例、女 4 例，年龄 10 个月（1 个月～20 岁），体重 10（2.5～68）kg。分析其临床结局，并随访生存病例，以初步了解其预后。结果住 ICU 时间 4（1～23）d，住院时间 12（6～21）d。死亡 3 例。21 例患者中，双心室矫治 6 例，单心室矫治 15 例。平均随访时间 3 年，5 年生存率 80%。结论完全性房室间隔缺损合并法洛四联症外科解剖矫治困难，多数病例仅可施行单心室矫治手术，部分病例可施行双心室矫治手术，远期预后良好。

肺动脉及分支量化分析在法洛四联症根治术中的意义

摘要 目的 对法洛四联症患者的肺动脉(PA)、左肺动脉(LPA)和右肺动脉(RPA)分支进行量化分析，探讨其临床意义。方法 术前测量236例法洛四联症患者PA及其分支直径，计算PA与主动脉(AO)直径比值(PA/AO)，PA与体表面积(BSA)比值(PA/BSA)，PA与正常肺动脉截面积(NPA)比值(PA/NPA)，(LPA+RPA)/AO，(LPA+RPA)/PA，(LPA+RPA)/BSA等；测量术后右心室与左心室收缩压比值(PRV/LV)，分析存活者与死亡者这些指标差别的意义。结果 (LPA+RPA)/AO＜0.5时，手术危险性显著增加；PA/BSA≥2.0时，(LPA+RPA)/BSA≥2.4及PA/NPA≥0.6时，其手术安全性显著增加；是否需跨肺动脉瓣环补片主要与PA/BSA，PVA/BSA，PA/NPA有关；术后PRV/LV比值与PA及其分支发育情况无关，而主要受术中右心室流出道和PA疏通情况的影响。结论 PA及其分支发育情况虽然对手术结果有影响，但更重要的是手术过程对右心室流出道及肺动脉狭窄的纠正情况。

Progress for the Echocardiographic Assessment of the Right Heart Function in Patients afer Surgical Repair of Tetralogy of Fallot

Evaluationthe right heart function has vital clinical value, especially in patients after surgical repair of tetralogy of Fallot(TOF).As an important tool used to assess the structure and function of heart, echocardiography has been used to evaluatethe right heart function of TOF after the surgery. This article reviews the current research on echocardiography techniques and right heart function in patients after surgical repair of Tetralogy of Fallot．

杂交技术在法洛四联症治疗中的应用

目的　总结法洛四联症（TOF）杂交手术的临床经验，探讨其手术技巧和效果。　方法　回顾性分析2006年7月至2012年7月广东省高州市人民医院重症TOF患者15例的临床资料，其中男10例、女5例，年龄4.2 （1.5～12.0） 岁，体重13.8 （10.0～42.0） kg。术前经超声心动图和螺旋CT检查确诊。外科术前介入治疗：所有患者行TOF根治术前均行侧枝血管栓塞术，其中2例采用AGA Plug血管塞封堵体肺侧枝血管，其余均采用COOK非可控弹簧圈栓塞体肺侧枝血管。侧枝血管栓塞术后立即行一期外科根治手术。　结果　15例患者中共发现体肺侧枝血管24支，封堵19支，未出现造影或封堵并发症，外科根治术后未出现灌注肺、低心排血量综合征等严重并发症。全组手术均效果满意，痊愈出院。住院时间8.5 （7～12） d。随访2年，无并发症，小儿患者发育正常。　结论　杂交手术治疗重症TOF安全、有效、可行，值得临床推广。

Right Ventricular Outflow Tract Reconstruction with Valved Bovine Jugular Vein Patch in Patients with Complex　Congenital Heart Disease

Objective　To evaluate early results of valved bovine jugular vein patch for reconstruction of the right ventricular outflow tract （RVOT）.?Methods　From May 2009 to March 2010， a total of 60 patients with complex　congenital heart diseases underwent reconstruction of RVOT with valved bovine jugular vein patch in Wuhan Asia Heart Hospital. There were 42 males and 18 females with their mean age of 6.2±8.9 years （ranging from 5 months to 33 years） and mean body weight of 27.5±24.0 kg， and 34 patients were less than 1 year. Preoperative clinical diagnosis included tetralogy of Fallot （n=38） and double outlet of right ventricle with pulmonary stenosis （n=22）. All the patients underwent one-stage surgical repair. Before operation， 4 patients underwent catheter intervention for their major aortopulmonary　collaterals. The diameters of pulmonary arterial ring of all the patients were 2 standard deviation less than normal range， and trans-annular patch was chosen for RVOT reconstruction. All the patients were postoperatively followed up for 18 to 26 months （mean 21.2±4.6 months）.?Results　There was no in-hospital death. And no second surgical intervention was needed for conspicuous RVOT stenosis or pulmonary regurgitation. Three patients needed reintubation for lung edema after extubation as a result of major aortopulmonary collaterals. Four patients underwent reexploration for postoperative bleeding. And all the other patients were discharged uneventfully. Mean cardiopulmonary bypass time was 84.0±22.0 min， and mean aortic cross-clamping time was 42.0±12.0 min. Mean RVOT gradient right after surgery was 18.0±4.5 mm Hg， which was not statistically different from mean RVOT gradient of 19.2±5.4 mm Hg measured by transthoracic echocardiography at their last postoperative follow-up（P＞0.05）. The degree of pulmonary regurgitation right after surgery was trivial in 32 patients（1＋）， mild in 28 patients（2＋）， which were not statistically different from the degree of pulmonary regurgitation at their last postoperative follow-up: trivial in 28 patients （1＋）， mild in 27 patients（2＋）， and moderate in 5 patients（3＋）. Calcification was not observed on the valved bovine jugular vein patch and valve cusp， and the valve cusp motioned well. No thrombosis or endocarditis was observed on the valved bovine jugular vein.?Conclusions　For patients with tetralogy of Fallot or double outlet of right ventricle （DORV） and pulmonary stenosis， valved bovine jugular vein patch is a good choice for trans-annular reconstruction of RVOT. There is no severe postoperative complication related to bovine jugular vein， the RVOT pressure gradient does not increase significantly， and anti-regurgitation result is satisfactory in short-term follow-up. Further follow-up is required to evaluate its long-term outcome.