ObjectiveTo investigate the effect and incidence of residual leakage after surgical repair of large ventricular septal defects with moderate to severe pulmonary hypertension using cross-linkage mattress suture, a suture method invented by us, as compared with interrupted mattress suture. MethodsWe retrospectively analyzed the clinical data of 41 patients of large ventricular septal defect with moderate to severe pulmonary hypertension underwent surgery using cross-linkage mattress suture in Beijing Anzhen Hospital from February 2011 through April 2013. The 41 patients were as a cross-linkage group (average age 18.7±12.3 years, the ratio of male to female 31:10). Another 41 patients, who were repaired using interrupted mattress suture, were retrospectively chosen by matching age, size and location of the defects, pulmonary artery pressure and vascular resistance with members from the cross-linkage group, and were assigned as a control group (average age 17.4±11.8 years, the ratio of male to female 31:10). ResultsThere was no operative mortality and no new perioperative atrioventricular conduction block. Postoperative echocardiography revealed the incidence of residual leakage was 31.7% (13/41) in the control group, 0% (0/41) in the cross-linkage group with a statistical difference (χ2=13.164, P=0.000). With a follow-up of 18.2±6.1 months, no late death and no new atrioventricular conduction block occurred. There was no statistical difference in New York Heart Association functional class or pulmonary artery pressure measured through echocardiography between the two groups. While there was a statistical difference in incidence of residual leakage between the the cross-linkage group and the control group (0% (0/41) versus 26.8% (11/41), χ2=10.499, P=0.001). ConclusionThere is a high incidence of residual leakage after the surgical repair of large ventricular septal defect complicated with moderate to severe pulmonary hypertension using interrupted mattress suture, while the use of cross-linkage mattress suture can effectively reduce the incidence of residual leakage.
Objective To evaluate long-term outcomes of surgical repair for pulmonary atresia with ventricular septal defect （PA-VSD） and major aortopulmonary collateral arteries （MAPCAs）.?Methods?We retrospectively analyzed the clinical data of 29 patients with PA-VSD and MAPCAs who underwent surgical repair in Shanghai Children’s Medical Center from February 2001 to February 2010. There were 13 patients in the one-stage operation group and 16 patients in the staged operation group. There were 8 males and 5 females in the one-stage operation group with their age ranging from 8 to 168 （26.0±17.0）months. There were 9 males and 7 females in the staged operation group with their age ranging from 4 to 149 （26.5±15.8）months. Eight patients underwent their second operation with the time interval between the two operations ranging from 14 to 40 （28.3±11.7） months. For MAPCAs， 9 patients underwent unifocalization， 16 patients underwent ligation or occlusion via cardiac catheterization， and the other 4 patients left them open or unrepaired. We compared postoperative mortality， complications， long-term outcomes， and quality of life between the two groups. Quality of life of the 29 PA-VSD patients was measured according to Pediatric Quality of Life Inventory version 4.0 and compared with 100 children from a kindergarten as a control group.?Results?Postoperative mortality of one-stage operation group was significantly higher than that of staged operation group at 15.4% （2/13） vs. 0.0% with χ2=4.12 and P=0.04. There was no statistical difference in the rate of postoperative complications between the two groups at 75.0% （9/12） vs. 56.2% （9/16） with χ2=0.51 and P=0.47. Patients were followed up for 3 to 88 months， and the follow-up mortality of one-stage operation group was not significantly higher than that of staged operation group at 27.3% （3/11） vs. 6.2% （1/16） with χ2= 2.28 and P=0.13. There was no statistical difference in overall quality of life score between one-stage operation group and staged operation group （66.7±8.6 vs 70.2±13.0， t?=?-0.71， P=0.48） . The overall quality of life score of PA-VSD patients was significantly lower than that of control group （68.7±11.2 vs. 77.8±15.7， t?= 3.14， P=0.01）， mainly because the physical functioning score of PA-VSD patients was significantly lower than that of control group （57.7±11.7 vs. 83.0±19.6， t?=5.67， P=0.00）， but there was no statistical difference in emotional well-being score， social functioning score， and school functioning score between PA-VSD patients and the control group.?Conclusion It is the key to analyze different pulmonary artery conformation， choose individualized surgical procedure and properly manage MAPCAs so as to reduce postoperative mortality and complications of surgical repair for patients with PA-VSD and MAPCAs.
Abstract: Objective To investigate the prognosis of residual shunt after surgical repair in infants. Methods We selected 407consecutive infant patients (255 males and 152 females) with venticular septal defects(VSD) between January 2008 and June 2008 in Shanghai Children’s Medical Center, Shanghai Jiaotong University. Of the patients, 273 were less than 1 yearold, 88 were 12 yearsold, and 46 were 23 years old. All of whom underwent surgical repair of the ventricular septal defect with autologous pericardial defect treated by glutaraldehyde. Results Of the 407 patients, 29 had residual ventricular septal defects, there was no significant difference among age groups in the rate of residual shunts （χ2=0.054，P=0.973）.Twentynine patients were followedup,and in the followup period of 1.5 months to 2 years postsurgery, 26 patients had spontaneous closure, while the other 3 patients did not heal. None of the patients needed reoperation. There was no significant difference amongage groups or type of ventricular septal defect in the rate of residual shunts (χ2=1.035，P=0.596). Conclusions Postsurgical residual ventricular septal defects smaller than 0.4 cm will close spontaneously in most infants.
Objective To investigate the surgical treatment methods and effects for pulmonary atresia with ventricular septal defect (PAVSD) in elder children and adults in order to promote the treatment effects. Methods From October 1996 to October 2008, we performed stage1 or staged biventricular repair on 39 PAVSD patients including 21 males and 18 females, ranging from 8 to 27 years old with an average age of 13.43 years. There were 14 cases of type A, 11 cases of type B, and 14 cases of type C. Among them, 23 patients underwent stage1 radical repair in which either human blood vessel with valves or bovine jugular vein with valves were used to connect the pulmonary artery and the right ventricular outflow tract. In these 23 patients, 3 patients complicated with major aortopulmonary collaterals(MAPCAs) underwent unifocalization (UF) operation. The other 16 patients received staged repair, including 9 cases of systemic to pulmonary artery shunt and 7 of staged radical cure. Results There were 6 perioperative deaths with a total mortality of 15.38%(6/39), including 4 (17.39%) stage1 radical repair cases and 2 (12.50%) staged radical repair cases. The former 4 were all type C patients, dying from low cardiac output due to increased pulmonary arterial pressure. In the latter 2 deaths, 1 was a type B secondary shunt patient, and the other was a type C staged radical repair case, both of whom died of bleeding caused by aortic injury in the succeeding operations. Followup was done on 28 cases with a followup rate of 84.85%. The followup time ranged from 14.0 months to 9.2 years with 5 cases missing. No patient died during the followup, and 9 patients maintained their cardiac function at class Ⅰ, 13 at class Ⅱ, 5 at class Ⅲ and 1 at class Ⅳ. Three patients had aortic valve regurgitation of small to medium volume, the treatment of which included an administration of oral potassium diuretic medication and regular follow-up. Conclusion Pulmonary vessels of elder children and adults with PAVSD are usually injured severely and oftentimes it is complicated with MAPCAs. Standard for stage1 radical repair should be defined more strictly based on the present one.
Objective Comparing postoperative change of blood gas and hemodynamic status in patients underwent a right ventricletopulmonary artery (RVPA) conduit or a modified BlalockTaussig (mBT) shunt for pulmonary atresia with ventricular septal defect and without major arterial pulmonary collaterals (MAPCAs), to affirm the effect on oxygen supply /demand with different procedure. Methods From July 2006 to October 2007, 38 patients with pulmonary atresia and ventricular septal defect without MAPCAs were divided into two groups according to different procedures: RVPA group (n=25) and mBT group (n=13).Perioperative mortality, blood gas and hemodynamic data during postoperative 48 hours, including heart rate, blood pressure, systemic oxygen saturation, mixed venous oxygen saturation, oxygen excess factor, inotropic score were compared in both groups. Results The difference in the mortality between RVPA group (4.0％，1/25) and mBT group （7.7％，1/13) showed no statistical significance（Pgt;0.05）. The total of 33 patients were followed up, the followup time was from 6 to 18 months.11 patients (4 patients in mBT group, 7 patients in RVPA group) underwent corrected procedures during 9 to 18 months after palliative procedures, one case died of elevated pulmonary vascular resistance and right ventricle failure. The mixed venous oxygen saturation at 24h and 48h after surgery were higher than that at 6h after surgery (Plt;0.01) both in RVPA group and mBT group. The systolic blood pressures at 6h, 24h, 48h after surgery in RVPA group were lower than those in mBT group (P=0.048，0.043， 0.045)，the mean systemic blood pressures in RVPA group were higher than those in mBT group (P=0.048, 0.046, 0.049),the diastolic blood pressures in RVPA group were higher than those in mBT group (P=0.038, 0.034, 0.040)， the inotropic scores in RVPA group were lower than those in mBT group (P=0.035， 0.032，0.047). Conclusion The blood pressures and inotropic scores are found significantly different in RVPA conduit and mBT procedures, while postoperative systemic oxygen delivery areequivalent. Both RVPA and mBT patients decline to nadir in hemodynamic status at 6 h after surgery.
Abstract: Objective To investigate the clinical anatomy of ventricular septal defect(VSD) in tetralogy of Fallot(TOF)，reassess its classification and technique of surgical closure. Methods The data of one hundred consecutive patients with TOF (between January 2002 and June 2006) were reviewed. Their ages ranged from 2 months to 13 years, weights ranged from 5 to 38kg, percutaneous oxygen saturation(SpO2) ranged from 57％ to 92％, haematocrit(HCT) ranged from 0.34 to 0.74, Nakata index ranged from 90 to 210mm2/m2 and McGoon ratio ranged from 0.8 to 2.0. The clinic anatomy of the VSD was studied intraoperatively. Results Among them, seventy one patients had fibrous continuity between the leaflets of the aortic and tricuspid valve. Ninteen patients had a muscular postero-inferior border. Ten patients had subpulmonary VSD’s. There was no third degree atrioventricular block (3°AVB). Two patients had transient-atrioventricular dissociation but subsequent returned to sinus rhythm. Twenty two patients had incomplete right bundle branch block. Three patients were found to have very small residual VSD (less than 0.2cm) in the posteroinferior borders which closed spontaneously after 6 months. ConclusionVSD in TOF when classified as peri-membranous, muscular and subpulmonary VSD may improve the accuracy of surgical closure.
Abstract： Objective To investigate the outcome of continuous shallow stitching repairing perimembranous ventricular septal defect(pVSD). Methods From January 2002 to October 2004,50 patients less than 10kg of body weight with simple pVSD were chosen in our hospital. VSD was repaired by continuous shallow stitching with autograft pericardium. Results The aortic clamping time was 32±21min（14-52min）, cardiopulmonary bypass time 56±35min（29-69min）.No Ⅲ° atrioventricular conduction block happened, 9 patients developed right bundle branch block, and 2 patients showed junctional rhythm. Two patients with perimembranous extending outlet were repaired because of residual shunt(0.4cm,0.3cm) on the anterosuperior rim of defect. One patient with trivial residual shunt(0.15cm) on the posteroinferior rim of defect was found closed spontaneously six months later. Tricuspid valve was incised in 10 patients of VSD sextending outlet,8 patients vertical to the valve ring,2 patients parallel to the valve ring. Moderate tricuspid valve regurgitation was found in 1 patient, mild in 5 patients, trivial in 4 patients. No one aggravated. One patient complicated with pericardial effusion.One patient was reoperated because of bleeding. Conclusion Continuous shallow stitching repairing pVSD is effective.
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.
Surgical treatment of complete transposition of great arteries with ventricular septal defect and pulmonary stenosis (TGA/VSD,PS) consists of Rastelli procedure, Lecompte procedure, Nikaidoh procedure, Yamagishi procedure and Ross-Konno switch procedure. Rastelli procedure and Lecompte procedure cause less myocardial lesion but more late complications. Nikaidoh procedure and Yamagishi procedure achieve better anatomical repair but involve more myocardial lesion. Ross-Konno switch procedure has a narrow surgical indication. So for patients with TGA/VSD,PS, different surgical methods should be used according to surgical indications and individual conditions. In this paper, the advantages and disadvantages, indication, contraindication, outcome and prospect of them are reviewed.
Objective To recognize and reevaluate the pathologic anatomic classification of ventricular septal defect （VSD）. Methods From January,2002 to October,2004,119 patients less than 10kg of body weight with simple VSD whose pathologic anatomic classification was determined by preoperative echocardiography and ascertained during surgery were choosed randomly. Results （1） There were fihy-one patients with perimembranous VSD （diameter 0. 6±1.0 cm）, 8 VSD situated in the membranous septum （diameter 0. 5±0.4 cm）, 21 VSD extending to inlet （diameter 0.8±0.5 cm）, 14 extending to outlet （diameter 1.0±0. 6 cm） and 8 extending to trabecula （diameter 0. 8±0.6 cm）. In this group, accessory tricuspid valve tissue was formed in 14 patients（diameter 0. 5±0.3 cm）. （2） Twenty-one patients had conoventricular VSD （diameter 1.2±0. 8 cm）, among them 13 VSD had muscle margins, 8 extending to membranous septum, 14 had septal band hypertrophy, and 5 had subaortic stenosis. （3） Twenty-six patients had subpulmonary VSD（diameter 0.8±0.8 cm）, 18 VSD lay immediately below pulmonary valve, 8 had muscle distant from pulmonary valve, 20 lay completely below pulmonary valve, and 6 lay below pulmonary valve and aortic valve. （4） Ten patients were atrioventricular canal type or inlet VSD （diameter 1.2±0.8 cm）. （5）Eleven patients had muscular VSD, among them 3 were single ,and 8 multiple （diameter 0. 4±0.3 cm）. Conclusion It will be more clinically significant that VSD is classified into perimembranous, conoventricular, atrioventricular canal or inlet, muscular and subpulmonary artery or conical types.