Objective To investigate clinical features and risk factors of prolonged postoperative recovery of pediatric patients in ICU after total cavopulmonary connection（TCPC），provide evidence for risk stratification management strategy， and enhance their postoperative recovery. Methods We conducted a retrospective analysis of clinical data of 81 patients undergoing TCPC in Fu Wai Hospital from January 2010 to July 2012. Three patients who died postoperatively were excluded from analysis. Prolonged postoperative recovery was defined as patients whose postoperative mechanical ventilation time was longer than that of 75% of all the patients. A total of 78 patients were divided into normal recovery group and prolonged recovery group. There were 59 patients in the normal recovery group including 34 male and 25 female patients with their age of 62.5±20.7 months，and 19 patients in the prolonged recovery group including 11 male and 8 female patients with their age of 64.8±29.8 months. Perioperative variables were compared between the two groups. Results The average cardiopulmonary bypass time of all the 81 patients was 107.6±54.1 （33-350） minutes. The average aortic cross-clamping time of 17 patients was 46.4±31.5 （22-143） minutes. Three patients （3.7%） died postoperatively because of severe low cardiac output syndrome and thrombosis in the extracardiac conduit. The mechanical ventilation time and ICU stay were 7.5 hours and 1.6 days respectively in the normal recovery group，which were both significantly prolonged in the prolonged recovery group. Preoperative high hemoglobin level，coexistence of intracardiac anomalies，longer cardiopulmonary bypass time，and non-fenestrated procedure were the main risk factors of prolonged postoperative recovery. Conclusion Early extubation and fast track recovery can be achieved in most of TCPC patients. Risk stratification management strategies may contribute to successful postoperative recovery of critical patients after TCPC.
Abstract： Objective To summarize early clinical result of total cavopulmonary connection, and analyze the risk factors contributing to prolonged postoperative recovery. Methods Between February 2009 and August 2010, 58 patients with functional univentricular complex congenital heart disease received total cavopulmonary connection in Beijing Fu Wai Hospital. All of them were diagnosed by echocardiogram and angiography including 26 patients with single ventricle, 10 patients with tricuspid atresia, 4 patients with pulmonary artery atresia, 5 patients with double outlet rightventricle, 1 patient with transposition of great arteries, and 12 patients with corrected transposition of the great arteries.Fifty seven patients underwent extracardiac conduit total cavopulmonary connection, and only one patient underwent total cavopulmonary connection with an intracardiac lateral tunnel. According to their postoperative pleural drainage volume and duration, these 58 patients were divided into a large pleural drainage volume group (17 patients with 10 males and 7 females, mean age of 8.61±6.73 years）that included patients with large volume and long duration of pleural drainage, and a little pleural drainage volume group (41 patients with 15 males and 26 females, mean age of 7.21±4.24 years) . A univariable analysis was conducted to compare the risk factors that effected recovery result between the two groups. Results There was no death in hospital period. The average length of hospital stay was 12.30±9.80 d . Average drainage time (18.00±5.50 d versus 5.00±2.20 d , t= -1.967, P ＜ 0.05）, drainage volume (12.30±2.60 ml/(kg·d) versus 2.80±1.70 ml/(kg·d), t=-3.221, P ＜ 0.05), and hospital stay (20.10±7.20 d versus 7.20±1.10 d, t=-2.003, P ＜ 0.05） of the large pleural drainage volume group were significantly larger or longer than those of the little pleural drainage volume group. Univariate analysis showed that preoperative pulmonary pressure measured by catheter in the large pleural drainage volume group was significantly higher than that in the little pleural drainage volume group (17.42±5.34 mm Hg versus 13.91±5.22 mm Hg，t=-2.073，P ＜ 0.05). Conclusions The mortality and major morbidities after total cavopulmonary connection are low in the current era. Preoperative high pulmonary pressure is a risk factor for large amount of pleural drainage and prolonged recovery.
Abstract: Objective To summarize the clinical experience for complex congenital heart disease treated with modified Fontan operation. Methods From November 1996 to May 2005,124 patients (male 83,female 41; including tricuspid atresia, single ventricle, double outlet of right ventricle, malposition of great arteries, pulmonary atresia, corrected transposition of great arteries, hypoplastic rightheart syndrome, etc.) underwent modified Fontan operation at age 7.6±5.5 years. Noncardiopulmonary bypass was used in 19 patients, 105 patients with cardiopulmonary bypass. Right atria-pulmonary artery connection were performed in 17 patients, right atria-ventricular connection were performed in 19 patients, and total cavopulmonary connection (TCPC) were performed in 88 patients. Staged operation were performed in 23 patients. Results The hospital mortality (30 days postoperative) was 13.7% (17/124). The hospital mortality of patients undergone right atria-pulmonary artery connection was 23.5%(4/17), patients undergone right atria-ventricular connection was 15.8%(3/19), patients undergone TCPC was 11.4%(10/88), patients undergone operation with fenestration was 14.6%(6/41), and the patients undergone staged operation was 8.7%(2/23). Low cardiac output syndrome, multiple organ failure, and ventricular fibrillation were the cause of death. Morbidity of complications was 16.9％(21/124) in early period. Complications consisted of pleural effusion, arrhythmia, pericardial effusion and low cardiac output syndrome, etc. Eightynine patients were followed up, followup time was from postoperative 6 months to 65 months. Re-hospitalization rate was 6.5%, and re-operation rate was 0.9%. There were pleural effusion in 3 patients, pericardial effusion in 3 patients, and obstruction of inferior vena cava in 1 patient. All patients recovered. Conclusion Modified Fontan operation is an optimal procedure for functional single ventricle, fenestration seems to decrease postoperative pleural effusions.
Objective To investigate the value and significance of the changes of plasma level of brain natriuretic peptide（BNP） in evaluating ventricle performance of functional single ventricle after total cavopulmonary connection （TCPC）. Methods We studied 11 patients with functional single ventricle undergone TCPC procedure after 2.1 years, who were followed-up at our ward between April 2004 and November 2004, 7 of them were males and 4 of them were females （TCPC group）. The clinical heart function of patients was scored according to the modified scoring system described by Ross. We obtained 3ml blood samples from the extremital vein of all subjects. Blood was collected into chilled tubes containing EDTA and aprotinin （4.5mg and 1 500u/ml blood, respectively）. The blood samples were promptly centrifuged （-4℃, 3 000r/min for 10 min） and the plasma was separated. BNP concentration was determined using immunoradiometric assay kits. Magnetic resonance imaging （MRI） examination was undertaken in 6 patients of TCPC group to analyse the relative factors with the change of BNP. Control group included 9 healthy children. Results （1） Median plasma BNP level for TCPC group and control group was 400pg/ ml （IQR200-690） and 110 pg/ml （IQR90-190）, respectively. There was a significant difference in plasma BNP between them （P=0. 003）. （2） The results of the index of heart function of TCPC group determined by MRI were 65. 76±8. 65 ml/m2 in end-diastolic volume index, 31. 90±6. 36ml/m2 in end-systolic volume index, 39.09±11.76ml/m2 in stroke volume index, 0. 52± 0. 06 in ejection fraction（EF）, 2.38±0.58L/min·m2 in cardiac index （CI）, 103.49±21.57g/m2 in mass index and 1.57±0.24 in mass/EDV. （3） The plasma BNP level for TCPC group was significant correlation with operation ages（r=0.632, P=0.041 ）. There was no correlation between plasma BNP level with EF, CI, score of Ross, gender, ages, percutaneous oxygen saturation（SpO2） and the type of dominant ventricle, respectively. Conclusions Raised concentration of plasma BNP in patients 2 years after undertaken TCPC procedure indicates that nervous-endosecretory system is still under stress condition. This pattern suggests that neurohormonal activation is primarily related to the altered postoperative physiology. the significance of BNP in patients of functional single ventricle after undertaken TCPC is different from tat in biventricular physiology patiens. The plasma BNP level could not be correctly evaluated the cardiac function after TCPC operation.
Objective To evaluate the clinical outcomes of total cavopulmonary connection (TCPC) and bidirectional Glenn shunt for treating complex congenital heart diseases with single functional ventricles. Methods From January 2002 to May 2004, twelve children, who had complex congenital heart diseases with single functional ventricles, underwent TCPC and bidirectional Glenn shunt. Among them, male was 3 and female was 9. Ages were from 4 to 13 years and body weights were from 14 to 34 kilograms. The diseases included mitral atresia 1 case, tricuspid atresia 3 cases, right ectopic heart with transposition of great arteries 3 cases, D-transposition of great arteries 3 cases, and single ventricle 2 cases. Results Eleven children survived and one child died in acute renal failure 19 hours after operation. The hospital mortality was 8.3%. Four children had chyle-thorax postoperatively, and eight children had uneventful recovery. In the follow-up period, one child died 12 months postoperatively for pulmomary arteriovenous fistula, and there were no complications like severe arrhythmia, thrombosis and cerebral problems. Conclusions TCPC and bidirectional Glenn shunt are safe and effective techniques for treating complex congenital heart diseases with single functional ventricles, and the clinical outcomes are satisfactory. The key points for the successful operation are big enough cava-pulmonary anastomosis as well as aggressive perioperative management.
Objective To summary the experience of extracardiac conduit total cavopulmonary connection (TCPC) and study the operative indication, design, method, and therapeutic efficacy. Methods 29 patients of extracardiac conduit TCPC were reviewed:the average age was 10 years. Of them, there were 9 cases of tricuspid atresia, 9 double inlet ventricle with left ventricular type, 3 mitral atresia, 3 corrected transposition of the great arteries with anatomically right ventricular hypoplasia and 5 double outlet of right ventricle with left ventricular hypoplasia. All patients underwent cardiopulmonary bypass, 12 cases with heart arrested, and 17 without heart arrested. In them, 20 cases’ superior vena cava were anastomosed directly to the upper margin of right pulmonary artery, 9 cases deviated to the left side of right pulmonary artery to enlarge the stoma. For the inferior vena cava stoma, 22 cases’ anterior walls of right atrium were partially incised, and sutured to the posterior wall, then anastomosed with Gore-Tex blood vessel prostheses and connected to pulmonary trunk, and the other 7 cases’ bottom of right atrium was totally incised, the proximal was closed, and the distal was anastomosised with Gore-Tex blood vessel prostheses and connected to the lower margin of right pulmonary artery, deviated to the right sidedness. Results 5 died in the first 22 cases, and the next 7 cases all survive. All patients were followed up for 3 months to 10 years with no late death. Of them, 12 cases had low cardiac output syndrome, and 11 cases of chylothorax. Conclusions Compared with other types of Fontan operation, the extracardiac conduit TCPC has better long-term effects in older or grown-up children. Nevertheless, strict operative adoption, reasonable operative design, refined procedures, carefully observation and treatment are the key points of improving therapeutic efficacy.
ObjectiveTo summarize clinical experience and outcomes of extracardiac conduit total cavopulmonary connection (TCPC)for surgical treatment of complex congenital heart diseases. MethodsClinical data of 52 patients who underwent extracardiac conduit TCPC from September 2006 to December 2012 in Department of Cardiac Surgery, Guangzhou General Hospital of Guangzhou Military Command were retrospectively analyzed. There were 12 patients who received one-stage extracardiac conduit TCPC. There were 40 patients who received two-staged extracardiac conduit TCPC after bidirectional Glenn procedure. Clinical data of all the patients were analyzed. Mortality, morbidity, length of hospital stay and intensive care unit (ICU)stay, mechanical ventilation time, change of arterial oxygen saturation (SaO2)were compared between the 2 groups. ResultsTwo patients (3.8%)died postoperatively including 1 patient with severe low cardiac output syndrome and another patient with multiple organ dysfunction syndrome. Fifty patients were discharged successfully. Mechanical ventilation time, length of ICU stay and hospital stay of the 40 patients who received two-stage extracardiac conduit TCPC were significantly shorter than those of the 12 patients who received one-stage extracardiac conduit TCPC. There was no statistical difference in postoperative morbidity, SaO2 (two-staged vs. one-staged:93%±3% vs. 94%±3%)or mortality (two-staged vs. one-staged:2.5% vs.8.3%)between the 2 groups (P > 0.05). Forty-five patients (90%)were followed up for 6-52 months, and there was no death during follow-up. At 3 months after TCPC, all the patients had heart function of class I or II, and echocardiography showed patent cavopulmonary anastomosis. ConclusionExtracardiac conduit TCPC is a simple procedure, can produce more physiological hemodynamic results, and can be performed for patients who cannot undergo biventricle procedure. Compared with one-stage extracardiac conduit TCPC, two-staged extracardiac conduit TCPC has wider surgical indications, can produce better postoperative recovery, and is easier to perform.
ObjectiveThe total cavopulmonary connection (TCPC) offers a palliation for the hemodynamic derangements associated with congenital heart lesions characterized by a single functional ventricle, but it may cause acute hepatic injury because of the special physiology. The objective of this study was to characterize hepatic function and its relationship to cardiac function in children who had undergone the Fontan procedure. MethodsWe retrospectively analyzed 114 children who had undergone TCPC operation in Shanghai Children's Medical Center between January 2013 and March 2014. There were 65 males and 49 females with a median age of 3.8 years (range 2.5 to 13.2) and a median weight of 14.8 kg (range 12.0 to 33.0). The study cohort was further divided into three groups according to the Child-Pugh classification. The total scores were calculated regarding to ascite, bilirubin, albumin, and international normalized ratio (INR). The scores from 4 to 5 were classified in Child A group, from 6 to 8 classified in Child B group, from 9 to 11 classified in Child C group. Thirty-four patients met criteria for Child Class A, 53 patients for Child Class B, and 27 patients for Child Class C. The univariate analysis and multivariable logistic regression model were used to compare demographic, anatomic, and physiological variables among the three groups. ResultsWithin the study population, 80 patients of Child B group and Child C group met criteria for acute hepatic injury. Univariate risk factors for acute hepatic injury included longer total bypass time (P=0.044), longer aortic cross-clamping time (P=0.005), longer ventilation time (P=0.000), higher postoperative mean pulmonary arterial pressure (P=0.000), elevated N-terminal pro-brain natriuretic peptide (P=0.001), higher vasoactive inotropic score (P=0.000), lower mixed venous oxygen saturation (SvO2, P=0.000) and arterial oxygen saturation (P=0.001), higher incidence of arrhythmia (P=0.000), and low cardiac output syndrome (P=0.003), the need of peritoneal dialysis (P=0.000). In the multivariable logistic model, the need for peritoneal dialysis (OR=17.018, 95%CI 5.117-56.602) and the lower postoperative SvO2 (OR=0.922, 95%CI 0.871-0.976) were two independent risk factors for acute hepatic injury after the TCPC. ConclusionThe need for peritoneal dialysis and lower postoperative SvO2 may represent the compound effects of multiple risk factors including preoperative hemodynamic and a marked hepatic vascular inflammatory response to surgery and cardiopulmonary bypass, which in turn may mediate acute hepatic injury.
ObjectiveTo analyze the outcomes of patients with one-stage Fontan procedure and short-term prognosis at a single institute. Method We retrospectively analyzed clinical records of 116 patients with one-stage Fontan procedure in our hospital from January 2008 through September 2013. There were 77 males and 39 females (36%), with median age 6.27 years (ranged 3.15 to 17.47 years) at the time of surgery and the median weight at 17.5 kg (ranged 10.0 to 80.0 kg). There were 55 patients with standard extracardiac conduit, 13 patients with direct extracardiac connection, 17 patients with intra-atrial or intra/extracardiac conduit, and 31 patients with lateral tunnel. ResultsMedian cardiopulmonary bypass time was 124 (61-256) minutes. Median cross-clamp time was 60 (19-152) minutes. There were six early deaths (5.1%). The overall median time of the cardiac intensive care unit stay was 4 (1-17) days, with a median ventilator support of 7.3 (1.0-181.0) hours. The mean room air saturation was 90.00%±4.68% before discharge. Median length of chest tube drainage was 10 (4-45) days. Multiple logistic analysis confirmed that heterotaxy syndrome was the only independent predictor for postoperative renal insufficiency. Operations with aortic cross-clamping (OR=26.184, 95% CI 1.712-400.451), preoperative sinus mode dysfunction (OR=6.777, 95% CI 1.495-30.721) and cross-clamp time over 60 minutes (OR=1.036, 95% CI 1.002-1.076) were predictors for prolonged chest tube drainage. A total of 110 patients were followed up for 17 (8-47) months with 2 deaths and 1 with thrombosis. No reoperation occurred. ConclusionThe one-stage Fontan procedure can be performed with satisfactory outcomes. Staged strategies for operations may be appropriately loosen for selected elder children.
ObjectiveTo summerize the early results of total cavopulmonary connection (TCPC) procedure with an extracardiac conduit in adults with congenital heart disease, and assess risk factors for postoperative delayed recovery in ICU. MethodsWe retrospectively analyzed the clinical data of 20 adult patients underwent TCPC operation with extracardiac conduit in Fu Wai Hospital between January 2012 and December 2014. There were 14 female and 6 male patients at age of 16 to 33 (20.45±4.33) years. ResultsThere was no hospital mortality. The time of ICU stay was 4.4±1.7 days. And time of hospital stay was 32.5±21.6 days. Morbidities included prolonged pleural effusion lasting more than 7 days in 12 patients (60.0%), new arrhythmias in 3 patients (15.0%), reexploration for bleeding in 3 patients (15.0%), surgical wound poor healing in 1 patient (5.0%). Dopamine and calcium were used in all the patients in the ICU, epinephrine in 18 patients, milrinone in 11 patients. Risk factors for postoperative delayed recovery in ICU were preoperative arrhythmias (P=0.02), cardiopulmonary bypass time longer than 120 min (P=0.04), plasma applications more than 2 000 ml (P=0.01), absence of fenestration (P=0.04), and pleural effusion lasting longer than 7 days (P=0.04). ConclusionThe TCPC procedure with an extracardiac conduit can be performed in adults with encouraged early results. Actively vasoactive drugs to maintain circulation early in ICU has good results for the patient's recovery.