Corresponding author: XU Zhi-wei, E-mail: zwxumd@online.sh.cn Abstract: Objective To compare the two different ways of right ventricle pulmonary artery (RV-PA) reconstruction at repair of persistent truncus arteriosus(PTA), the direct RV-PA anastomosis and extra conduit connection, in order to find the better way. Methods From Feb. 2000 to Sept. 2006, 23 patients had undergone the repairs of truncus arteriosus in our hospital, age at operation from 1.5 to 63.3 months. Patients were divided into 2 groups according to the way of RV PA reconstruction. Group Ⅰ : 18 of them, using direct RV-PA anastomosis, group Ⅱ : 5 of them, using valved homograft or Gore-Tex conduit. 3 patients were associated with interrupted aortic arch (IAA). Kaplan-Meier was used to calculate postoperative mortality, survival time and re-operation situation. Paired t-test and group t-test were used to evaluate late pulmonary growth and cardiac function.Results There were 2 early hospital death, there were 17 patients in follow-up for 2.14 ± 1.97y (32.00d-6.95y). No later death during follow-up. Total survival rateo was 91.30%(21/23), 95% CI of survival time was 5.55-7.15y. Survival ratio of group Ⅰ was 94.40%, and that of group Ⅱ was 80%. One patient had undergone re operation for right ventricular outflow tract obstruction (RVOTO). The difference between the diameter of postoperative RV-PA anastomosis was statistically significant. The early diameter of group Ⅰ was 1.01 ± 0.26cm, later was 1.32 ± 0.45cm(P=0.019). The velocity of flow at the position of anastomosis and the peristome of right pulmonary artery (RPA)/left pulmonary artery (LPA) was acceptable. Compared the postoperative cardiac function, late left ventricle ejection fraction (LVEF) really improved with a significant difference ［ group Ⅰ , early was 62.82%, late was 69.87%(P=0.026); group Ⅱ , early was 58.17%, late was 64.00%(P=0.029) ］ . No re-operation for truncal valve regurgitation was needed. Conclusions The postoperative survival and follow-up results are satisfactory. A direct anastomosis of RV-PA continuity has the potential for right ventricle outflow tract (RVOT) growth and associated with low rate of pulmonary artery and bifurcation obstruction. The heart function is really improved during follow-up. IAA and truncal valve regurgitation are two major risk factors of associated with hospital death.
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.
Based on the guidelines of the diagnostic test systematic review, this study elaborated the statistical processing of the pooling of data detailed in the systematic review of diagnostic test, discussed the methods for identification and handling of the heterogeneity, evaluated the advantages and disadvantages of the index of the accuracy in diagnostic tests, and proposed the identification method of the publication bias. It also took the data from the published article entitled “Diagnostic Value of ProGRP and NSE for Small Cell Lung Cancer: A Meta-Analysis” as an example for analysis and illustration, which presented clearly the data processing and interpretation of the systematic review of diagnostic test, in order to provide references for clinical researchers to study and conduct the systematic review of diagnostic test.
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 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.
Objective To investigate the efficacy and safety of the application of selective cerebral perfusion (SCP) technique in pediatric aortic arch reconstruction, so as to alleviate brain injury during operation. Methods From April 2007 to May 2008, 32 children aged from 8 days to 103 months (14.4±25.4 months) and weighed from 27 kg to 22.0 kg (6.7±4.4 kg) underwent aortic arch reconstruction with selective cerebral perfusion in Shanghai Children’s Medical Center. Twentytwo suffered from aortic coarctationwith intracardiac anomaly, and 10 suffered from interrupted aortic arch with intracardiac anomaly. The arterial cannulation was achieved by placing a flexible wire wound cannula in ascending aorta close to the root part of innominate artery. The rectal temperature was about 1820℃. Then the cannula was moved upward into innominate artery to perform SCP. Results The time of SCP was 17-121 mins（39.6±19.4 mins）, perfusion blood flow maintained in 15-40 ml/(kg·min)［29.7±6.1 ml/(kg·min）］. Four cases died of low cardiac output syndrome or arrhythmia, and no evidence of brain injury was observed. No obvious neurologic complication was observed in 28 survivls. No abnormal electroencephalogram was observed in 25 cases. The results of head Bsonography and brain magnetic resonance image (MRI) were normal in 5 neonates. Conclusion Selective cerebral perfusion is a simple, feasible, safe and effective technique in pediatric aortic arch reconstruction.
Objective To summarize the experiences of single stage repair of persistent fifth aortic arch associated with stenosis and interrupted aortic arch and other cardiac anomalies,and to improve surgical effect of the diseases． Methods From Jan．2000 to May 2008，five patients with persistent fifth aortic arch were operated in this hospita1，the age at operation was 1.8-108.0 months and body weight 3.7-31.0 kg．Three patients had chronic heart failure and respiratory infection repeatedly.All patients received single stage repair. Results There were two early hospital deaths，one patient’s parents gave up all the therapy because of cardiac insufficiency, pulmonary hypertension crisis and severe pulmonary infection; another one died of severe pulmonary hypertension crisis，the low cardiac outflow and left heart failure. Three patients were followed up, followup time was 55.67±48.64 months. The results were excellent,and one patient had been followed up for 8 years,the latest magnetic resonance imaging showed that diameter of the enlarged fifth aortic arch was 9.3 mm. Conclusion Persistent fifth aortic arch operation can achieve good exposure,less incisional wound and excellent recovery through midline sternotomy.Because of systemic hypertension and the affection of associated anomalies the operation should be performed as early as possible.