ObjectiveTo evaluate the application of portosystemic shunt after subcutaneous transposition of the spleen (STS) to orthotopic liver transplantation (OLT) in the rat. MethodsOne hundred and eighty Wistar rats were randomly divided into the group of orthotopic liver transplantation after portosystemic shunts by subcutaneous transposition of the spleen (STS+OLT group) and the group of orthotopic liver transplantation (OLT group). The two groups were further divided into A, B, C subgroups in the light of duration of anhepatic phase (phases were respectively less than 25 min, around 35 min and 45 min).There were fifteen rats in each subgroup. At the described intervals, blood samples were collected from the peripheral and portal vein for testing ALT, pH and endotoxin levels. The survival rates were also observed. Results The ALT value of all animals basically returned to normal levels on the 7th postoperative day in the STS+OLT group and the OLT A subgroup, but in OLT B subgroup, ALT was still remarkably elevated on the 7th postoperative day (P＜0.01), and returned to normal levels on the 30th postoperative day. The pH values and endotoxin levels from the portal vein of all animals in STS+OLT groups and OLT A subgroup had no significant difference (Pgt;0.05) at the beginning, the end of the anhepatic phase and at the time of reperfusion for 30 min. But in the OLT B and C groups, the pH values and endotoxin levels were significantly higher at the end of anhepatic phase and reperfusion for 30 min than those in the beginning of anhepatic phase (P＜0.01). The survival rates at postoperative different time points in both B and C subgroup of the OLT group were significantly lower than those in STS+OLT group animals (P＜0.05).Conclusion The portosystemic shunt by subcutaneous transposition of the spleen can notably improve both the success rate of the OLT procedure and the postoperative survival rate in the rat.
Abstract： Objective To investigate the early and mid-term outcomes of morphologic tricuspid valve replacement by means of intravalvular implantation in corrected transposition of great arteries（cTGA）. Methods From January 2009 to January 2012，11 patients with cTGA were surgically treated in Fu Wai Hospital. There were 9 male patients and 2 female patients with their mean of age of（37.8±11.7）years and mean body weight of（73.0±11.3）kg. All the patients underwent morphologic tricuspid valve replacement with preservation of the entire valvular and subvalvular apparatus. Simultaneous surgical procedures included repair of ventricular septal defect in 2 patients，repair of atrial septal defect in 4 patients，pulmonary valvuloplasty in 1 patient，reconstruction of functional right ventricular outflow tract in 4 patients and repair of coronary-pulmonary artery fistula in 1 patient. Postoperative New York Heart Association （NYHA） classification, cardiothoracic ratio, morphological right ventricle ejection fraction, end-diastolic dimension of morphological right ventricle and left atrium were evaluated during follow-up. Results All the 11 patients were successfully surgically treated and followed up for an average duration of（13.0±10.6）months. There was no statistical difference between postoperative and preoperative average cardiothoracic ratio （0.54±0.06 vs. 0.57±0.09，t=1.581，P＞0.05），morphologic right ventricle ejection fraction （52.8%±9.0% vs. 54.9%±9.5%, t =0.712，P＞0.05），and end-diastolic dimension of . morphological right ventricle （54.3±7.5 mm vs. 56.9±9.2 mm，t =0.988，P＞0.05）. There was statistical difference between postoperative and preoperative average end-diastolic dimension of left atrium（42.1±8.9 mm vs. 53.4±11.1 mm，t =3.286，P＜0.05）and NYHA classification（Z = -2.640，P＜0.05）. Conclusion Intravalvular implantation of morphologic tricuspid prosthesis can protect the physiological structure of morphologic right ventricular and prevent furtherdamage to its function caused by morphologic tricuspid valve insufficiency. Postoperative dimension of morphologic left atrium and cardiac function are significantly improved. The early and mid-term outcomes are satisfactory．
Abstract： Objective?To evaluate clinical experiences and long-term outcome of morphologic left ventricle （mLV） retraining for congenitally corrected transposition of the great arteries （cCTGA）. Methods From May 2005 to May 2011, 24 patients with cCTGA anomaly underwent left ventricle retraining by means of pulmonary artery banding in Fu Wai Hospital. There were 13 males and 11 females with their age of 0.17-22.00 （3.73±4.35） years and body weight of 5.10-61.00（15.71±10.95）kg. Major concomitant malformations included tricuspid valve insufficiency （TR）in 23 patients （mild in 11 patients, moderate in 7 patients, severe in 5 patients）, restrictive ventricular septal defect in 18 patients, atrial septal defect in 5 patients, patent foramen ovale in 5 patients, patent ductus arteriosus in 4 patients, mild pulmonary stenosis in 5 patients, and aortic coarctation in 1 patient. All the patients were preoperatively diagnosed by echocardiography, cardiovascular angiography or cardiac catheterization. The mLV end diastolic diameter （mLVEDD） was 8-32（21.56±6.60）mm, posterior wall thickness of mLV was 2-7 （4.29±1.52）mm , mLV to morphologic right ventricle （mRV） pressure ratio （mLV/mRV） was 0.12-0.65 （0.41±0.12）. Pulmonary artery banding operation was performed through upper partial sternotomy or median sternotomy without circulatory arrest. Results The mLV/mRV pressure ratio reached to 0.57-0.93 （0.76±0.10） under direct pressure monitoring after surgery. There was no in-hospital death in this group. Echocardiography before discharge showed that the structure and function of the two ventricles were good, the interventricular septum moved partially towards mRV, mLVEDD was increased slightly, and there was a tendency of reduced TR. Postoperative follows-up was from 1 to 35 months, and there was no late death during follow-up. All the patients were in good general condition with stable vital signs and New York Heart Association （NYHA） classⅠ-Ⅱ. The mLVEDD was 14-40 （26.17±7.11） mm, posterior wall thickness of mLV was 4-9 （4.95±1.44）mm, mLV/mRV pressure ratio was 0.52-0.98 （0.72±0.16） , and TR was significantly decreased. Fourteen patients successfully underwent staged complete double-switch procedure. Conclusion Left ventricle retraining is a safe and effective method to train mLV for cCTGA patients. Pressure load and posterior wall thickness of mLV are increased, mLV cavity is dilated, and TR is significantly reduced after the surgery.
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.
Abstract： Objective To evaluate clinical outcomes of pulmonary artery banding for morphologic left ventricular training in corrected transposition of the great arteries.?Methods?A total of 89 patients with corrected transposition of the great arteries underwent surgical repair in Shanghai Children’s Medical Center from January 2007 to December 2011 year. Among them, 11 patients underwent pulmonary artery banding, whose clinical records were retrospectively analyzed. Except that one patient was 12 years, all other patients were 3 to 42 （16.40±11.67） months old and had a body weight of 6 to 32 （11.70±7.20）kg. All the patients were diagnosed by echocardiogram and angiocardiogram.?Results?There was no postoperative death after pulmonary artery banding in 11 patients. The pulmonary arterial pressure/systemic blood pressure ratio （Pp/Ps） was 0.3 to 0.6 （0.44±0.09） preoperatively and 0.6 to 0.8 （0.70±0.04） postoperatively with statistical difference （P＜0.01）. Tricuspid regurgitation was mild in 2 （18.2%） patients, moderate in 5 （45.4%）, severe in 4 （36.4%）preoperatively，and none in 2（18.2%）patients, mild in 7 （63.6%），and mild to moderate in 2 （18.2%）postoperatively. Five patients underwent staged double-switch operation after pulmonary artery banding at 15.20±8.31 months, and 1 patient died. The other 6 patients were followed up for 18.83±3.43 months, and echocardiogram showed tricuspid regurgitation as trivial in 2 （33.3%）, mild in 3 （50.0%）, and moderate in 1 （16.7%）patient.?Conclusions?In patients with corrected transposition of the great arteries, pulmonary artery banding is helpful to reduce tricuspid regurgitation, and morphologic left ventricle can be trained for staged double-switch operation with good clinical outcomes. It is important to follow up these patients regularly to evaluate their morphologic left ventricular function and tricuspid regurgitation after pulmonary artery banding.
Abstract： Objective To analyze risk factors for perioperative mortality in the arterial switch operation (ASO), in order to provide better operation and decrease the mortality rate. Methods We enrolled 208 ASO patients including 157 males and 51 females at Fu Wai Hospital between January 1, 2001 and December 31, 2007. The age ranged from 6 h to 17 years with the median age of 90 d and the weight ranged from 3 kg to 43 kg with the median weight of 5 kg. Among the patients, 127 had transposition of great artery (TGA) with ventricular septal defect (VSD), and 81 patients had TGA with intact ventricular septum (IVS) or with the diameter of VSD smaller than 5 mm. Coronary anatomy was normal (1LCX2R) in 151 patients and abnormal in the rest including 15 patients with single coronary artery, 6 with intramural and 36 with inverse coronary artery. Preoperative, perioperative and postoperative clinical data of all patients were collected to establish a database which was then analyzed by univariate analysis and multivariate logistic regression analysis to find out the risk factors formortality in ASO. Results There were 24 perioperative deaths (11.54%) in which 12 died of postoperative infection with multiple organ failure (MOF), 10 died of low cardiac output syndrome, 1 died of pulmonary hypertension, and 1 died of cerebral complications. Among them, 20 patients (18.30%) died in early years from 2001 to 2005, while only 4 (4.00%) died in the time period from 2006 to 2007, which was a significant decrease compared with the former period (Plt;0.05). The univariate analysis revealed that cardiopulmonary bypass (CPB) time was significantly longer in the death group than in the survival group（236±93 min vs. 198±50 min, P=0.002）, and occurrence of major coronary events (33.3% vs. 2.2%, P=0.000) and unusual coronary artery patterns（33.3% vs. 6.5%,P=0.000） were much more in the death group than in the survival group. Multivariate logistic regression analysis showed that early year of [CM(159mm]operation (OR=7.463, P=0.003), unusual coronary artery patterns (OR=6.303,P=0.005) and occurrence of majorcoronary events (OR=17.312, P=0.000) were independent predictors for perioperative mortality. Conclusion The ASO can be performed with low perioperative mortality in our hospital currently. Occurrence of major coronary events, unusual coronary artery patterns and year of surgery before 2006 are independent predictors for perioperative mortality.
Objective To analyze the growth of anastomotic stoma of aortic(AO) and pulmonary artery (PA) after arteries switch operation(ASO) so as to assess the longterm efficacy of ASO . Methods The data of 331 patients who had undergone ASO in Shanghai Children’s Medical Center of Jiaotong University from December 1999 to December 2007 was analysed retrospectively. One hundred eleven patients had complete transposition of great arteries complicated with intact ventricular septum(TGA/IVS), 123 had complete transposition of great arteries complicated with ventricular septal defect(TGA/VSD), 73 had TaussigBing complicated with ventricular septal defect and pulmonary hypertension, and 24 underwent StageSwitch. Of the 331 patients 228 were followedup, and the followup time was 20.4±18.6 months. There were 752 ultrasonic cardiograph reports, 3.3per patient on average. The growth of anastomosis was analysed according to the diameters of AO and PA. Results The AO and PA anastomosis diameters of TGA/IVS patients（before discharge 0.74±0.17 cm and 0.65±0.13 cm, latest followup 1.09±0.31cm and 0.84±0.21 cm）, TGA/VSD patients (before discharge 0.76±0.20 cm and 0.63±0.14 cm, latest followup 1.09±0.24 cm and 0.82±0.22 cm) and TaussigBing patients（before discharge 0.84±0.25 cm and 0.74±0.20 cm, latest followup 1.05±0.30 cm and 0.85±0.24 cm） growed significantly（Plt;0.05）. The AO anastomotic stoma diameters of patients who had underwent StageSwtich (before discharge 0.93±0.19 cm, latest followup 1.19±0.29 cm) growed significantly（Plt;0.05）. The PA anastomotic stoma diameter growed（before discharge 0.90±0.27 cm, latest followup 1.00±0.32 cm）, but had no statistical significance (P＞0.05). Till November 2008, Six patients needed reoperation because of the right or left ventricle outflow tract obstruction. After reoperation, 3 had no residual obstruction, 3 had residual obstruction. Conclusion After the section and suture of ASO, aortic and pulmonary artery can grow with age, but sometimes stenosis happens to some patients. During the followingup, some patients need reoperation.
Objective To investigate the surgical indications and the mid and long term results of morphologic tricuspid valve replacement for corrected transposition of the great arteries（cTGA）. Methods From September 1997 to September 2007, 18 cases with cTGA were treated in Fu Wai Hospital. There were 15 male and 3 female, aged from 16 to 51 years（33.3±12.8 years）, and weighed from 47 to 90 kg(60.9±14.7 kg). There were 10 cases with isolated morphologic tricuspid valve insufficiency, 3 complicated with ventricular septal defect, 2 complicated with ventricular septal defect and pulmonary valve stenosis, 2 with morphologic tricuspid valve insufficiency after septal defect repair, and 1 with mechanical valve dysfunction after morphologic tricuspid valve replacement. The preoperative mean morphologic right ventricle ejection fraction was 562%±11.6%. Of the 18 cases, 12 were in grade Ⅱ and 6 were in grade Ⅲ according to New York Heart classification（NYHA）.All the cases had undergone morphologic tricuspid valve replacement. Postoperative indices such as cardiac function and morphological right ventricle ejection fraction were followed up. Results One patient died of postoperative low cardiac output syndrome. Two had pervavlvular leak, which were cured by pervavlvular leak repair at 7th and 30th day after operation, respectively. Sixteen were followed up with a followup time of 57.0±407 months. There was no statistical significance between preoperative and postoperative mean morphologic right ventricle ejection fraction（52.8%±9.2% vs.56.2%±11.6%; t=2.062, Pgt;0.05）. The followup showed that 12 were in NYHA grade Ⅰ or Ⅱ, and 4 were in NYHA grade Ⅲ. There was no statistical significance between preoperative and postoperative percentage of cases in NYHA grade Ⅲ（χ2=1.532，Pgt;0.05）. Conclusion Morphologic tricuspid valve replacement can prevent the further damage to morphologic right ventricular function caused by morphologic tricuspid valve insufficiency. The mid and long term results were satisfying. During the followup, the morphologic right ventricle can function appropriately.
Abstract: The complete transposition of the great arteries (TGA) is one of the commonest congenital cardiac anomalies in cyanosis. In untreated patients, death occurs early in infancy. Nowadays arterial switch operation (ASO) has been widely proposed to treat TGA without pulmonary valve stenosis. Meanwhile, surgical risks and mortality will be increased if TGA is accompanied by coronary arterial anomalies. So proper surgical management of abnormal coronary artery has a significant influence on the outcome of ASO. The classification, operation methods and surgical results were reviewed in this article.
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.