Abstract： Objective?To summarize the clinical experience，surgical technique and indication of coronary artery implantation with double flap extension technique in arterial switch operations （ASO） in D-transposition of the great arteries （D-TGA） and Taussig-Bing anomalies.?Methods?From January 2006 to June 2011， 21 patients （13 males and 8 females；age 110.0±84.5 d；weight 5.4±4.2 kg） with D-TGA or Taussig-Bing anomalies associated with complex coronary artery malformations underwent ASO with double flap extension technique for coronary artery implantation in Shanghai Children’s Medical Center affiliated to Medical College of Shanghai Jiaotong University. All the patients had a main trunk of right coronary artery or dilated right ventricular conus branch originated from the left or right aortic sinus，with abnormal course of anterior looping to the aorta. The double flap extension technique was described as followed： a long coronary button was excised as a flap from the aorta; another pedicle flap on the pulmonary artery （neoaorta） was cut to extend to the button of coronary artery with an equal distance; the side edges of the flap and the button were sutured together to form a lengthened coronary artery tube.?Results?No operative death occurred in hospital. The postoperative duration of mechanical ventilation was 101.6±53.6 h. The duration of ICU stay was 9.5±4.9 d. Postoperatively，low cardiac output syndrome occurred in 9 cases，pulmonary hypertension crisis in 2 cases，pneumonia in 6 cases，and acute kidney failure in 2 cases. Eleven patients underwent delayed sternum closure. All the patients were discharged after proper treatment. Follow-up was complete in 17 cases. The duration of follow-up was 2 months to 5 years. Growth and development were significantly improved in all the patients during follow-up. No patient had ischemic ECG changes. One patient underwent reoperation for supravalvular pulmonary stenosis 2 years after ASO.?Conclusion?Double flap extension technique for coronary implantation in complicated ASO can significantly decrease postoperative death due to coronary artery malformations，especially for patients who have two-stage ASO and patients whose main trunk of right coronary artery or dilated right ventricular conus branch originates from the left or right aortic sinus with abnormal course of anterior looping to the aorta.
Objective To summarize the clinical experiences of using the remaining coronary buttons to reconstruct the neoaortic root in the arterial switch operation (ASO) and discuss the clinical significance of preserving the morphology of aortic sinus in improving postoperative coronary artery perfusion. Methods From January 2003 to June 2009, 110 patients with transposition of great arteries (TGA) combined with ventricular septal defect (VSD ) or the Taussig Bing anomaly treated in our hospital were enrolled in this study. The patients were at the age between 2 days and 2 years averaged 91.1 days, and their body weight varied between 1.79 and 9.50 kg with an average weight of 4.70 kg. The patients were divided into two groups based on different surgical strategies. For group A (n=78), we reconstructed the neoaortic root with the remaining coronary buttons by shortening the diameter of the proximal neoaorta. While for group B (n=32), we excised the remaining coronary buttons with the aortopulmonary diameter mismatched. The risk factors of hospital mortality were analyzed with stepwise logistic regression. Results Twelve patients died early after operation with a death rate of 10.9% (12/110). Mortality in group A was significantly lower than that in group B ［6.4%(5/78) vs. 21.9%(7/32)，P= 0.019］. Clinical followup was completed in 72 survivors with the followup time of 3 months to 5 years after operation. Late death occurred in 3 patients including 1 in group A and 2 in group B. Five patients underwent reoperations. Univariate logistic regression analysis showed that risk factors for early postoperative death were TaussigBing anomaly (χ2=4.011,P=0.046), aortic arch anomaly (χ2=4.437,P=0.036), single coronary artery pattern (χ2=5.071,P=0.025) and patients in group B (χ2=5.584, P= 0.019). Multivariate analysis confirmed that the aortic arch anomaly (χ2= 5.681, P=0.010 ) and patients in group B (χ2=3.987, P=0.047 ) were two independent risk factors for early mortality after operation. Conclusion The modified technique which uses the remaining coronary buttons to reconstruct the neoaortic root can preserve the morphology of neoaortic root better. The special anatomical morphology of aortic sinus has close relation to the perfusion of coronary arteries. The lowering hospital mortality may be due to the better perfusion of the coronary arteries.
Abstract： Objective To investigate the longterm complications and preventions of rapid twostage arterial switch operation through longterm follow-up. Methods We reviewed the clinical information of 21 patients of rapid twostage arterial switch operation from September 2002 to September 2007 in Shanghai Children’s Medical Center. Among them, there were 13 males and 8 females with an average age of 75 d (29-250 d) and an average weight of 5 kg (3.5-7.0 kg). The data of left ventricle training period and the data before and after the twostage arterial switch operation were analyzed, and the risk factors influencing the aortic valve regurgitation were analyzed by the logistic multivariable regression analysis. Results The late diameter of anastomosis of pulmonary and aortic artery were increased compared with those shortly after operation (0.96±0.30 cm vs. 0.81±0.28 cm, t=-1.183,P=0.262; 1.06±0.25 cm vs. 0.09±0.21 cm, t=-1.833,P=0.094), but there was no significant difference. The late velocity of blood flow across the anastomoses was not accelerated, which indicated no obstruction. The late heart function was better than that shortly after operation, while there was no significant difference between left ventricular ejection fraction(LVEF) during these two periods (62.88%±7.28% vs. 67.92%±7.83%,t=1.362,P=0.202). The late left ventricular end diastolic dimension(LVDd) was significantly different from that shortly after operation (2.16±0.30 cm vs.2.92±0.60 cm，t=-5.281，P=0.003). Compared with earlier period after operation, the thickness of left ventricular posterior wall thickness（LVPWT）was also increased (0.39±0.12 cm vs. 0.36±0.10 cm,t=0.700,P=0.500), but there was no significant difference. The postoperative aortic valve regurgitation was worsened in 4 patients (30.77%, 4/13), not changed in 7 patients and alleviated in 2 patients compared with that before operation. There was no severe regurgitations during the followup. The logistic regression analysis showed that the small preoperative diameter ratio of aortic valve to pulmonary valve and long follow-up time were two risk factors for the [CM(159mm]aggravation of aortic regurgitation. Conclusion There is a relatively high aortic regurgitation rate after rapid two stage arterial switch operation, but there is no later death or reoperation and the survival conditions are satisfactory. All patients must be followed up periodically to check the anastomosis of pulmonary and aortic arteries and the aortic valve.
Abstract: Objective To summarize the clinical experiences of resection with patch aortoplasty for infant coarctation of the aorta combined with aortic arch hypoplasia. Methods Between May 2007 and December 2009, 49 patients including 30 males and 19 females with coarctation with hypoplastic aortic arch underwent coarctation resection and patch aortoplasty in Shanghai Children’s Medical Center, School of Medicine, Shanghai Jiaotong University. The age of the patients ranged from 23 days to 3 years and 1 month with thirtyfour patients under 6 months, ten between 6 months and 1 year old, and five more than 1 year old. The surgery under deep hypothermia cardiopulmonary bypass with selective cerebral perfusion were performed in 31 cases and circulation arrest in 15 cases; under moderate hypothermia cardiopulmonary bypass in 3 cases. Pericardia patch was used in 31 cases, pulmonary autograft patch in 14 cases and xenograft pericardia patch in 4 cases. The associated intracardiac anomalies were repaired in the same stage. Results One case died from circulation failure during the perioperative period. The operative mortality was 204% (1/49). Low cardiac output syndrome and renal failure respectively occurred in 5 cases and 1 case who were cured afterwards by correspondent treatments. No residual obstruction was detected by echocardiography after the operation. Followup was carried out in fortyeight cases for a minimum of 4 months and a maximum of 3 years. Echocardiographic examination showed that the gradient through the aortic arch was more than 40 mm Hg and computed tomography showed recoarctation in 1 case who underwent reoperation eight months after the operation; the gradient was more than 20 mm Hg in 2 cases who were under continuous observation; all the rest cases had a fine aortic arch morphology and for these patients, the blood velocity at descending aortic arch was not obviously changed during the followup period compared with that right after operation, the computed tomography showed a normal aortic arch geometry. Left bronchus compression was relieved obviously or totally disappeared in patients who suffered from left bronchus stenosis before the operation without any aortic aneurysm detected. Conclusion Coarctation resection with patch aortoplasty is considered as an optimal surgical method for management of infant coarctation with hypoplastic aortic arch.
Objective To compare perioperative results between transventricular and transatrialtransventricular approaches in repairing tetralogy of Fallot (TOF), and to improve the surgical results. Methods The data of 1 423 consecutive patients who underwent complete repair of TOF between January 1998 and December 2007 were reviewed. 736 patients were repaired by the transventricular approach,and 687 patients by the transatrialtransventricular approach. Results Patients repaired by transventricular approach decreased from 100% in 1998 to 65% in 2002, and by transatrialtransventricular approach increased from 35% in 2002 to 79% in 2007. Aortic clamping time, cardiopulmonary bypass (CPB) time,mechanical ventilation time,and intensive care unit (ICU) stay in patients repaired by transatrialtransventricular approach had less than those in patients repaired by transventricular approach. No difference in transvalve patch ratio.There was lower morbidity in patients repaired by transatrialtransventricular approach in one to two organ systems dysfunction than that in patients repaired by transventricular approach. No difference in three or more organ systems dysfunction between them. Rate of residual ventricular septal defect(VSD), right ventricule to mean pulmonary artery (MPA) pressure gradient, tricuspid regurgitation, pulmonary artery regurgitation and arrhythmia in patients repaired by transatrialtransventricular approach were less than those in patients repaired by transventricular approach. Reoperative rate and mortality in patients repaired by transatrialtransventricular approach were less than those in patients repaired by transventricular approach. Conclusion TOF repair by the transatrialtransventricular approach fits to the actual conditions in China.
Objective To summarize the treatment experiences of Modified lateral tunnel(LT) Fontan operation on complex congenital heart disease in children and investigate the advantages of this operation. Methods From March 1999 to August 2008, 86 patients with cynosis complex congenital heart disease underwent LT Fontan operation in our hospital. There were 47 male and 39 female aged 1.9-11.5 years with a mean age of 4.7 years and weighed 8.6-52.0 kg with a mean weight of 17.0 kg. There were 33 cases with asplenia syndrome, 17 cases with polysplenia syndrome, 11 cases with tricuspid atresia(TA), 11 cases with double outlet right ventricle(DORV) of atrioventricular discordance, 8 cases with complete transposition of great arteries(D-TGA) complicated with pulmonary stenosis, 5 cases with corrected transposition of great arteries(cTGA) and 1 case with Ebstein’s anomaly. Unilateral superior bidirectional superior cavopulmonary anastomosis(BSCPA), bilateral bidirectional superior cavopulmonary anastomosis and hemiFontan opertion were done before operatipon. The time between two operations was 0.7-7.8 years（3.6±2.9 years）. LT Fontan operation(LT-group, 47cases) and Modified LT Fontan operation(M-LT group, 39cases) were used in operation to drain blood from inferior vena cava to right pulmonary artery. Partly completed secondstage M-LT Fontan operation. Results There were 7 deaths in two groups(9%), 5 in LT group and 2 in M-LT group. There was no statistical significance（χ2=0.865，P=0.448）. In stagemodified LT Fontan operation, there were significantly more cases who had BSCPA operation preoperatively in MLT group than that in LT group. Twentytwo cases had low cardiac output syndrome after operation, 13 cases underwent peritoneal dialysis because of renal dysfunction, and theirurine volume recovered after 2-5 days’ dialysis. There were significantly more cases who had arrhythmia in LT group than that in M-LT group（χ2=8.763，P=0.003）. The time of chest drainage was longer in LT group than that in M-LT group（t=2.970，P=0.003）. The follow-up time was 3 months8 years. No death was found. In M-LT group 33（85%） cases were followed up and in LT group 39（83%）cases were followed up. No severe complication was found. Patients’ activity ability improved significantly. Conclusion The M-LT Fontan operation is an advanced operation to improve the success rate of operation and reduce postoperative complications.
Objective To summarize clinical experience of a single stage surgical approach on patients with TaussigBing anomaly combined with side by side relationship of great arteries. Methods From May 2000 to Sep. 2007, 26 patients (age 3.1±2.2 months) with TaussigBing anomaly with side by side great arteries underwent the single stage operation, including arterial switch operation (n=25), and Kawashima operation (n=1). Aortic arch obstruction was present in 13 patients. The corrections of aortic arch obstruction included descending aorta end to end anastomosis to aortic arch or end to side anastomosis to ascending aorta. Results The hospital mortality rate was 11.5% (3/26). There was no operative death in continuous 15 patients after Jun. 2005. 21 patients were followed up for 1 to 5 years. The patients’ growth and development were improved obviously. The sizes of the hearts were smaller than those before operations. The pulmonary blood flow was decreased obviously. Two patients required re-operations because of supravalvular pulmonary stenosis. Conclusion Taussig-Bing anomaly with side by side great arteries has complex anatomical characters. In order to improve the operative outcomes, the optimized operative strategies should be considered in according with different anatomies.
Abstract: Objective To review the shortterm outcome of modified Nikaidoh operation, aortic translocation and biventricular outflow tract reconstruction as an alternative surgical procedure for the treatment of transposition of the great arteries with ventricular septal defect and pulmonary stenosis (TGA/VSD/PS). Methods Between January 2004 and December 2005, 8 consecutive patients had undergone Nikaidoh procedure for the treatment of TGA/VSD/PS at Shanghai Children’s Medical Center. All patients had ventriculoarterial discordance and atrioventricular concordance. Associated lesions included a straddling atrioventricular valve in one patient and hypoplastic left pulmonary artery. The median age at operation was 11.4±7.6months (4 to 29months). Weight of body was 8.0±1.9kg (5.2 to 11.0kg). No patient had previous palliative procedure. The surgical technique used was a modification of the Nikaidoh procedure. Results The median total cardiopulmonary bypass time was 176±50 minutes (range,112 to 250 minutes), and the median aortic crossclamp time was 101±27 minutes (range, 73 to 139minutes). The median length of stay in the intensive care unit was 12±9 days, with a median hospital stay of 19±12 days. There was 1 hospital death as a esult of severe left ventricle failure. There was no residual left ventricular outflow tract obstruction (LVOTO) and right ventricular outflow tract obstruction (RVOTO), but 3 patients with mild to moderate pulmonary regurgitation and 4 patients with moderate. At a median follow-up of 8.8 months (range, 3 to 18months), all patients were alive. All have the normal ventricular function. There were ejection fraction (EF) 0.64±0.02 and fractional shortening (FS) 0.33±0.02. None of the patients developed aortic insufficiency and progressed LVOTO or RVOTO. Conclusions Nikaidoh procedure is a valuable surgical option for TGA/VSD/PS in infant, especially in the presence of “inadequate anatomy” for a Rastelli repair. Big evidence and longer follow-up are required to fully assess the potential longterm benefits of this procedure compared with the Rastelli repair.
Objective To summarize the early experience of modified Nuss procedure with thoracoscope for repairing pectus excavatum in children. Methods Fiftythree pediatric pectus excavatum were treated by modified Nuss procedure with thoracoscope from June 2004 to July 2006, theage ranged from 2.4 to 16.0 years, the average age was 8.1 years. Thirtysix patients were symmetric pectus excavatum and 17 patients were asymmetric pectus excavatum. Results The operation in all patients were successful, the average blood loss was less than 10ml. Pericardium perforation occurred in 2 earlier patients during the operation, pneumothorax occurred in 6 patients postoperatively,pleural effusion occurred in 3 patients, and all resolved by corresponding treatments. The average hospital length of stay was 5.5 days. All patients had a satisfied deformity correction and no needs of transfusion. The depression was thoroughly corrected in 48 patients, residual depression was less than 20% of preoperative degrees in 5 patients. Therapeutic results evaluation showed excellent in 46 patients and good in 7 patients. All patients were followed up in 1-25 months without any complaints, the activity ability was same as normal children; there were no bar displacement and injury event occurred. The bar had been removed in 1 patient 24 months after surgery who still kept in excellent results. Conclusion Modified Nuss procedure is easy to be performed with minimal invasion and good shortterm results. Thoracoscopic visualization facilitates the safety of this technique. It is recommendable to be tried and extended applied.
Objective To analyze the outcome of arterial switch operation （ASO） for surgical repair of complete transposition of the great arteries （TGA）, and to investigate the risk factors influencing the mortality of ASO. Methods The clinical data of patients suffered from TGA and treated with ASO from the January 2003 to December 2004, and the clinical records in hospital including eehoeardiogram and operation record were collected. The clinical data were analyzed by chi-squared test and logistic muhivariable regression analysis, including the age undergone operation, body weight, diagnosis, anatomic type of coronary artery, cardiopulmonary bypass time, aortic crossclamping time, circulation arrest time, assisted respiration time after operation, the delayed closure of sternum and so on. The risk factors influencing the early mortality of the ASO were analyzed. Results Sixty seven patients were operated with ASO, five patients died during the peri-operative period. The outcome of univariate analysis indicated that risk factors influencing the mortality of ASO included： age（P=0. 004）, body weight （P=0. 042）, anatomic type of coronary artery （P= 0. 006） and extracorporeal circulation time （P= 0. 048）, the length of the CICU stay（P= 0. 004） and the hospital stay（P=0. 007） after operation in the TGA/VSD patients were longer than those in TGA/ IVS patients. The logistic muhivariable regression analysis indicated that the age at operation （P= 0. 012）, coronary arteries anomaly （P = 0.001 ）and the longer cardiopulmonary bypass time （P = 0. 002） were correlated with the increase of death rate. Conclusion It could be good results for TGA patients who was repaired with ASO. The age at operation, the coronary arteries anomaly and the longer cardiopulmonary bypass time are the risk factors influencing the mortality.