Tetralogy of Fallot (TOF) is the most common cyanotic congenital heart disease. It is characterized by an interventricular communication with an overriding aorta, subpulmonary obstruction, and consequent right ventricular hypertrophy. The potential for late complications is an important concern for growing number of survivors after surgical repair, although long-term survival rates are excellent. Progressive pulmonary valve regurgitation leading to right heart failure and arrhythmias are common late complications and major reasons of mortality. In this review, we focus on research progress of pathogenesis and treatment of late complications after TOF repair, and the importance of long-term follow-up is emphasized.
ObjectiveTo summarize cardiopulmonary bypass (CPB) management experience in tetralogy of Fallot (TOF) infants weighing less than 8 kg. MethodsA total of 120 TOF infants weighing less than 8 kg received surgical repair in Wuhan Union Hospital from July 2009 to August 2013. There were 85 males and 35 females with their age of 1-18 months and body weight of 4-8 kg.The diagnosis of all the patients was made with echocardiography and diagnostic cardiac catheterization. Moderate hypothermia or profoundly hypothermic CPB with low-flow perfusion was used according to different surgical procedures. Imported membrane oxygenators and 4:1 cold blood cardioplegia were used. Zero-balance ultrafiltration during CPB and modified ultrafiltration during rewarming were performed. ResultsCPB time was 65-200 (115.3±9.6) minutes, and aortic cross-clamping time was 40-110 (60.3 ±10.2) minutes. A total of 112 patients received moderate hypothermia and low-or moderate-flow perfusion, and 8 patients received profound hypothermia and low-flow perfusion. Ultrafiltration volume was 780.5±50.3 ml, and hematocrit (HCT) increased to 0.35-0.40 after modified ultrafiltra-tion. Heart beat was automatically recovered in 114 patients (95%) after aortic unclamping. Weaning off CPB was successful in 119 patients, and 1 patient received extracorporeal membrane oxygenation because of difficult weaning from CPB. Postoperative mechanical ventilation time was 26.5±14.5 hours, and length of ICU stay was 121.5±16.5 hours. Five patients died of low cardiac output syndrome, and the other 115 patients were discharged successfully. ConclusionAppropriate hemodilution and colloidal pump priming solutions, perfusion methods suitable with surgical procedures, 4:1 cold blood-potassium cardioplegia, continuous zero-balance ultrafiltration during CPB and modified ultrafiltration during rewarming to maintain reasonable HCT and colloid osmotic pressure are all crucial factors in CPB management for surgical repair of TOF in infants.
ObjectiveTo investigate clinical outcomes and risk factors of patients with valvular heart disease (VHD) and giant left ventricle undergoing heart valve replacement (HVR). MethodsClinical data of 144 VHD patients with giant left ventricle who underwent HVR in Union Hospital of Tongji Medical College, Huazhong University of Science and Technology from January 2009 to December 2012 were retrospectively analyzed. There were 116 male and 28 female patients with their age of 15-69 (44.9±11.9) years and disease duration of 57.8±98.3 months (range, 1 month to 40 years). There were 92 patients with rheumatic VHD, 28 patients with degenerative VHD, 15 patients with congenital VHD, and 9 patients with infective endocarditis. A total of 137 patients who were discharged alive were followed up. Risk factors of postoperative mortality, morbidity and late death of VHD patients with giant left ventricle undergoing HVR were analyzed with t-test, chi-square test or Fisher's exact test, and logistic regression analysis. The life-table method was used to calculate long-term survival rate and draw the survival curve. ResultsMajor postoperative complications included low cardiac output syndrome (LCOS) in 19 patients (13.2%), ventricular arrhythmias in 56 patients (38.9%), prosthetic paravalvular leaks in 7 patients (4.9%), pleural effusion in 33 patients (22.9%), pericardial effusion in 8 patients (5.6%), liver failure in 23 patients (16.0%), and renal failure in 5 patients (3.5%). Seven patients (4.9%) died postoperatively. Logistic univariate analysis showed that advanced-age ( > 50 years), rheumatic VHD, higher preoperative NYHA class (Ⅲ or Ⅳ), long disease duration, poor preoperative left ventricular function[left ventricular ejection fraction (LVEF) < 40%], double valve replace-ment (DVR), other concomitant intracardiac procedures, prolonged cardiopulmonary bypass (CPB) time and aortic cross-clamping time, postoperative LCOS and ventricular arrhythmias were risk factors of early mortality of VHD patients with giant left ventricle undergoing HVR (P < 0.05). Logistic multivariate analysis showed that advanced age ( > 50 years), long disease duration, higher preoperative NYHA class (Ⅳ), poor preoperative left ventricular function (LVEF < 40%), DVR, prolonged CPB time were independent predictors of early mortality (P < 0.05). Logistic multivariate analysis showed that higher preoperative NYHA class (Ⅲ or Ⅳ), other concomitant intracardiac procedures, poor preoperative left ventricular function (LVEF < 50%) were independent predictors of postoperative LCOS (P < 0.05). Higher preoperative NYHA class (Ⅲ or Ⅳ) and preoperative non-sinus rhythm were independent predictors of postoperative ventricular arrhy-thmias (P < 0.05). Within 2 weeks after the operation, left ventricular end-diastolic dimension (LVEDD), left atrial diameter (LAD), LVEF and left ventricular fractional shortening (LVFS) were all significantly reduced compared with preoperative parameters (P < 0.05). Five patients died during follow-up. One-year, 2-year, 3-year and 4-year survival rates were 97.1%, 95.0%, 92.7% and 92.7% respectively. Preoperative LVEF, LVEDD and NYHA were significantly different between patients who died or survived during follow-up. ConclusionsHVR can produce low postoperative mortality, high long-term survival rates and satisfactory clinical outcomes for VHD patients with giant left ventricle. Advanced age ( > 50 years), long disease duration, higher preoperative NYHA class (Ⅳ), preoperative non-sinus rhythm, poor preoperative left ventricular function (LVEF < 40%), DVR and prolonged operation time may be risk factors of postoperative mortality and morbidity. Poor preoperative left ventricular function and significantly enlarged left ventricle may be risk factors of late death after HVR.
ObjectiveTo evaluate the changes of left ventricular morphology and contractile function of patients with mitral stenosis and small left ventricle after mitral valve replacement. MethodsStudies on the changes of left ventricular morphology and contractile function of patients with mitral stenosis and small left ventricle after mitral valve replacement were searched from the databases of Wangfang, VIP, CNKI, PubMed, Elsevier Science Direct, and Cochrane Library from establishment to January 2015. Quality of articles was evaluated. Relevant data were extracted from eligible studies to conduct meta-analysis. Mean differences (MD) of left ventricle end-diastolic volume index (LVEDVI), left ventricle end-diastolic diameter (LVEDD), left ventricular ejection fraction (LVEF) and left ventricular fraction shortening (LVFS) between the preoperative and the postoperative value from eligible studies were analyzed and pooled, and their 95% confidence intervals (CI) were calculated. R2.15.3 software was applied for statistical analysis. ResultsEight eligible studies involving 446 patients were analyzed in the study. The quality of included literature was high. The results of meta-analysis showed that LVEDVI and LVEDD increased by 14.51 ml/m2 with 95%CI -22.78 to -6.25 (P<0.01) and 4.88 mm with 95%CI -10.85 to 1.09 (P=0.11) respectively at 2 weeks postoperatively compared with preoperative value. LVEF decreased by 3.05% with 95%CI -3.02% to 9.12% (P=0.32) while LVFS increased by 1.16% with 95%CI -4.83% to 2.50% (P=0.53) at 2 weeks postoperatively. Compared with preoperative value, LVEDVI and LVEDD markedly increased by 16.11 ml/m2 with 95%CI -20.32 to -11.90 (P<0.01) and 10.56 mm with 95%CI -11.52 to -9.60 (P<0.01) respectively at 6 months postoperatively. LVEF and LVFS increased by 7.69% with 95%CI -17.18% to 1.8% (P=0.11) and 6.21% with 95%CI -10.07% to -2.36% (P<0.01) respectively at 6 months postoperatively compared with preoperative value. ConclusionLeft ventricular morphology and contractile function of patients with mitral stenosis and small left ventricle recovers well after mitral valve replacement.
ObjectiveTo compare clinical results of different anticoagulation methods for patients with large left atrium in the early period after mitral valve replacement (MVR) in order to optimize anticoagulation therapy for them. MethodsA total of 144 patients with large left atrium who underwent MVR in Union Hospital of Tongji Medical College from January 2012 to September 2013 were included in this study. There were 76 male and 68 female patients with their age of 36-60 (47.4±7.0) years. All the patients were divided into 2 groups according to different anticoagulation methods after MVR. Group A patients received warfarin anticoagulation since the 2nd postoperative day. Group B patients received warfarin and aspirin (0.1 g daily) since the 2nd postoperative day. Morbidity and mortality during follow-up were compared between the 2 groups. ResultsInternational normalized ratio (INR) was 2.03±0.11 in group A and 2.01±0.11 in group B,and there was no statistical difference between the 2 groups (t=0.804,P>0.05). Twenty patients (13.9%) had hemorrhagic complications. There was no statistical difference in INR between patients with hemorrhagic complications in group A and B (t=0.496,P>0. 05) and there was no statistical difference in hemorrhagic rate between group A and B(P>0. 05). There was no thromboembolic complication in group B,and 9 patients (6.3%) in group A had thromboembolic complications. Three patients (2%) died of intracranial hemorrhage in group A during follow-up. Two patients died in group B,including 1 patient with recurrent pericardial effusion and pericardial tamponade who died 60 days after surgery,and another patient who died of unknown reason during follow-up. ConclusionFor MVR patients with large left atrium,anticoagulation with warfarin and aspirin can significantly decrease the incidence of thromboembolic complications but does not increase the incidence of hemorrhagic complications.