ObjectiveTo quest the risk factors of poor prognoses in children with tetralogy of Fallot (TOF) during perioperative period and evaluate its clinical application values.MethodsA retrospective analysis of the clinical data of 119 children who underwent one-stage correction of TOF in Guangdong Provincial People's Hospital from September 2016 to January 2019. The cohort includes 75 males and 44 females, with ages ranging from 3.2-137.1 (13.2±1.4) months and weights ranging from 4.6-21.0 (8.3±0.2) kg. Perioperative poor prognosis was defined as duration of mechanically assisted ventilation >48 h or secondary intubation, vasoactive-inotropic score (VIS) within 48 h >40, postoperative length of stay >14 d, and the occurrence of the major adverse events. Major adverse events were defined as early death, malignant arrhythmia, low cardiac output syndrome, non-fatal cardiac arrest, postoperative reintervention, diaphragm paralysis, and other clinical complications. Univariate and multivariate logistic analyses were used to analyze the correlation between risk factors and poor prognoses.ResultsThere was 1 perioperative death, and 9 with major adverse events. Variables selected by Least Absolute Shrinkage and Selection Operator (LASSO) included 2 preoperative variables (McGoon index, aortic root diameter index) and 4 intra-operative variables [left-right direction of bicuspid pulmonary valve, total length of right ventricular outflow tract (RVOT) incision index, pulmonary valve with commissurotomy, and minimum temperature in cardiopulmonary bypass (CPB)]. Univariate and multivariate logistic analyses were used to the above factors, respectively. The variables with statistical significance (P≤0.05) were McGoon index, aortic root diameter index, left-right direction of bicuspid pulmonary valve, and minimum temperature in CPB. A nomogram was established based on the above factors, and the results showed that the left-right direction of bicuspid pulmonary valve was more risky than the tricuspid pulmonary valve and the anterior-posterior direction of bicuspid pulmonary valve. The lower the McGoon index, the higher aortic root diameter, and the lower temperature in CPB, the higher risk of poor prognostic events in children with TOF.ConclusionThe left-right direction of the pulmonary bicuspid valve has a higher risk of poor prognosis than the tricuspid pulmonary valve and the anterior-posterior direction of bicuspid pulmonary valve. With the smaller McGoon index and the larger aortic root diameter, the risk of poor prognoses in children with TOF is higher. The temperature in CPB being lower than medium-low temperature obviously relates to the high incidence of poor prognostic events, which can be used as an auxiliary reference standard for decision-making in pediatric TOF surgery in the future.
ObjectiveTo investigate if the ratio of pulmonary valve annulus, which is the proportion of pulmonary valvular annulus size to total size of aortic valvular annulus and pulmonary valvular annulus, can better guide the choice of surgical approach than the value of z.MethodsA retrospective analysis was made for 254 patients who underwent total correction of tetralogy of Fallot in Guangdong General Hospital between January 2016 and January 2018. There were 154 males and 100 females with an average age of 14.60±18.76 years. The patients were categorized into two groups, a transannular patch group (TAP, n=164) and a non-TAP group (n=90). The sizes of pulmonary and aortic valvular annulus were evaluated in each group, and the cutoff value of proportion of pulmonary valvular annulus for TAP was calculated.ResultsBoth proportion of pulmonary valvular annulus and z-scores were smaller in the TAP group than those in the non-TAP group (0.29±0.06 vs. 0.36±0.06, P<0.001; –4.04±2.13 vs. –2.06±1.84, P<0.001, respectively). In receiver operating characteristics analyses, proportion of pulmonary valvular annulus and the z-score cutoff values were 0.353 (area under the curve 0.781, 95%CI 0.725–0.831) and –2.13 (area under the curve 0.766, 95%CI 0.709–0.817), respectively, demonstrating that the proportion of pulmonary valvular annulus was a more powerful diagnostic tool as a predictor of TAP.ConclusionOur results suggest that the proportion of pulmonary valvular annulus is an effective predictor for TAP and can be easily applied to clinical practice.
Abstract: Objective To investigate the method of improving effect, by investigating and analyzing the possible risk factors affecting shortterm outcome after total correction of tetralogy of Fallot (TOF). Methods Data of 219 patients who received total correction of TOF were divided into two groups according to the length of postoperative stay in hospital and recovery of heart function in the near future. Group A(n=110): patients had good recovery of heart function classified as gradeⅠorⅡ（NYHA classification）, and could smoothly be discharged from the hospital within two weeks without serious complications. The left ventricular ejection fraction (LVEF) had to exceed to 0.50 during 6 months followup visit. Group B(n=109): patients had worse recovery of heart function classified as grade Ⅱ or Ⅲ, and could not be discharged within two weeks with severe complications. LVEF was less than 0.50 during 6 months followup visit. The clinical data of two groups were compared, and risk factors affecting shortterm outcome after total correction of TOF operation were analyzed by logistic regression and model selection. Results There were good recovery of heart function classified as gradeⅠorⅡ(NYHA classification）in discharge, no death, and LVEF all exceeded to 0.50 in group A; there were 8 deaths in group B (7.34 %), and recovery of heart function was worse classified as grade Ⅱ or Ⅲ, with LVEF being less than 0.50（Plt;0.01）. Amount of postoperative daily thoracic drainage, assisted respiration time, time of inotropic agent stabilizing circulation, and the average length of postoperative stay in group A were all less or short than those in group B（Plt;0.01）. But the bypass and clamping time of group B were exceeded group A. The ratio of patching astride annulus in group B was greater than that in group A, and Nakata index was less than that in group A(Plt;0.01). The results of logistic regression and model selection indicate: age at repair (OR=0.69), oxygen saturation(OR=0.98), haematocrit before operation (OR=0.94), and patching astride annulus (OR=46.86), Nakata index (OR=16.90), amount of postoperative daily thoracic drainage (OR=0.84), presence of arrhythmia(OR=0.87), and wound infection(OR=63.57) have significant effect with shortterm outcome after total correction of TOF operation. Conclusions The probable methods to improving effect of shortterm outcome after total correction of TOF are an earlier age at repair, decreasing haematocrit, rising oxygen saturation before surgery, performing a palliative operation facilitating development of arteriae pulmonalis in earlier time, improving the surgical technique, and strengthening the perioperative care.
Abstract: Objective To analyze the surgical treatment of tetralogy of Fallot (TOF) with anomalous coronary artery (ACA) crossing the right ventricular outflow tract (RVOT), in order to improve the outcome of the disease. Methods The clinical data of 26 patients of TOF with ACA crossing the RVOT of Fu Wai Hospital from Oct.1996 to Feb.2006 were analyzed retrospectively. A double ventriculotomy superior and inferior to ACA were used in 11 patients, one ventriculotomy inferior to ACA were used in 6 patients and superior to ACA for 4 patients, 2 patients needed extra cardiac conduits, and 3 patients received other approaches. Results There were 2 operative death （7.7%）and no late deaths. Follow-up was extended 1 to 100 months, all of them had no residual ventricular septal defect(VSD) and their right ventriclepulmonary artery gradient were 27.3±15.6 mmHg. Conclusion Preoperative identification of ACA in patients with TOF is necessary. The surgeon should be careful in inspection of distribution of coronary artery during operation, and undergo the individualized surgical procedures based on the extent of RVOT obstruction and distribution of the ACA.
Tetralogy of Fallot (TOF) is the most common cyanotic congenital heart disease. It is characterized by an interventricular communication with an overriding aorta, subpulmonary obstruction, and consequent right ventricular hypertrophy. The potential for late complications is an important concern for growing number of survivors after surgical repair, although long-term survival rates are excellent. Progressive pulmonary valve regurgitation leading to right heart failure and arrhythmias are common late complications and major reasons of mortality. In this review, we focus on research progress of pathogenesis and treatment of late complications after TOF repair, and the importance of long-term follow-up is emphasized.
Abstract: Objective To summarize the experience of surgical treatment of tetralogy of Fallot (TOF) with anomalous coronary artery. Methods From March 1993 to April 2006, 22 patients with TOF and anomalous coronary artery underwent repair. The resection of hypertrophied parietal, septal band and the ventricular septal defect (VSD) repairs were performed by trans-right ventricular outflow tract (RVOT) approach in 5 cases, and by transatrial approach in 17 cases, which consisted of 7 cases required a transannular patch to enlarge a pulmonary annulus, construction of a double barrel outlet in 6 cases, by autologous pericardium conduit (3 cases), homograft (1 case) and reflected anterior wall of the main pulmonary artery in combination with bovine pericardium (2 cases). Results There was one operative death because of the anomalous coronary artery impairment. The accessory left anterior descending artery was severed because it was mistaken for the conal arteryin 1 case, which caused failure to wean from bypass, after the left internal mammary artery was anastomosed to the accessory left anterior descending artery, the cardiopulmonary bypass (CPB) was stopped successfully. Mean early gradient(ΔP) was 23.4mmHg and ΔP＞20mmHg in 9 cases. Eighteen cases were followed up, mean time was 13.2 months. Late ΔP＞20mmHg in 7 cases, and ΔP were less than 20mmHg in 11 cases. Conclusion The repair of TOF with anomalous coronary artery is more safe by using the transatrial approach. The surgical reconstruction of RVOT depends on the anatomic characteristic of anomalous coronary artery.
Objective To investigate the optimal timing for surgical treatment of infants less than six months of age with tetralogy of Fallot (TOF), and to improve surgical results and reduce early mortality. Methods Clinical material of 108 consecutive patients with TOF who were less than six months of age undergoing early surgery from Oct.1996 to Dec. 2006 were retrospectively reviewed. There were 70 males and females with mean age of 4.70 months (9 d-6 months). 104 patients underwent complete repair and four patients underwent BlalockTaussig (B T) shunt. Emergency procedures have been performed in 5 patients. Results Five patients (4.63%) died of low cardiac output syndrome (3 patients), pulmonary infection and acute respiratory distress syndrome (1 patient), and acute necrotizing enteritis (1 patient).82 patients were followed up, followup period was 31.17±40.00 months.21 patients lost to followup. One patient(0.92%) required additional intervention for pulmonary valve stenosis 6 months after operation. Heart functional class(New York Heart Association) recovered toⅠ-Ⅱgrading in other patients. Echocardiography shows: no residual ventricular shunt, no stenosis in right ventricular outflow tract and pulmonary valve, pressure difference≤50 mm Hg. No late deaths. Conclusion Early definitive repair of TOF can be performed safely on infants less than six months of age, the results of low mortality is acceptable.
ObjectiveTo investigate the incidence, pathogens, risk factors and clinical outcomes for ventilator- associated pneumonia (VAP) in children after tetralogy of Fallot (TOF) surgical correction, in order to offer reliable data for the prevention of VAP.MethodsThis was a retrospective study performed in Guangdong General Hospital and 181 children (121 males, 60 females, mean age of 11.2±10.4 months) undergoing surgical correction for TOF were included. ALL the children who received mechanical ventilation for 48 hours or longer between January 2013 and December 2017 were classified into a VAP group (n=44) and a non-VAP group (n=137). T test, χ2 test and multiple logistic regression analysis were used to identify the possible risk factors for VAP.ResultsThis study enrolled 181 patients , of which 44 were diagnosed as VAP. And the incidence of VAP was 24.3%. The most frequent isolated pathogen was Gram-negative bacteria (69.7%). Single factor analysis showed that the variables significantly associated with a risk factor of VAP were: hypoxic spells, preoperative pneumonia, preoperative mechanical ventilation support, cardiopulmonary bypass (CPB) time, reintubation, pulmonary atelectasis, low cardiac output syndrome (LCOS), intra-abdominal drainage and transfusion of fresh frozen plasma. The multiple logistic regression showed CPB time (OR=1.011), reintubation (OR=14.548), pulmonary atelectasis (OR=6.139) and LCOS (OR=3.054) were independent risk factors for VAP in children after TOF surgical correction. Patients with VAP had prolonged duration of mechanical ventilation, a longer ICU stay and longer hospitalization time.ConclusionsThe VAP rate in this population is higher than that reported abroad, which leads to prolonged duration of mechanical ventilation and a longer hospital stay. The effective measures for prevention of VAP should be taken according to the related risk factors for VAP to decrease the incidence of VAP in children after TOF surgical correction.
Abstract: Objective To evaluate the results of surgical treatment of tetralogy of Fallot in adults． Methods From July 2002 to August 2009，75 adult patients with tetralogy of Fallot received surgical treatment in Xijing Hospital, ForthMilitary Medical University．There were 35 males and 40 females, with age at l7 to 37 years (23.30±3.50 years), and eoperativehemoglobin at 143 to 231 g/L(172.00±31.00 g/L)．All these patients were diagnosed by.echocardiograph before operation. All the patients were received tetralogy of Fallot of corrective operation in the hypothermia cardiopulmonary bypass. A total of 46 patients had a transannular right ventricular outflow tract patch，and 29 patients had a non ansannular patch． Results Operation time was 157 to 276 min(221.32±41.34 min), cardiopulmonary bypass time was 68 to 163 min(91.71±28.35 min) and aorta intercepted time was 37 to 96 min（55.47±23.61 min）. There were 6 operative deaths with an operative mortality at 8.00％. The causes of death were low output syndrome(n=3)，acute renal failure(n=2)， and multiple organ failure(n=1)．Nine patients needed reoperation for postoperative bleeding(12.00％)．We followed up 69 patients from 3 to 56 months (26.31±7.40 months). There were 2 patients with trivial residual shunt. The cardiac function status were New York Heart Association(NYHA) Ⅰ to Ⅱ in the 69 patients．No late death occured． Conclusion The effectiveness of surgical treatment for adults with tetralogy of Fallot is satisfactory．
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.
