Objective To discuss the methods and results of the surgical treatment of apical muscular ventricular septal defects （VSD） , in order to improve the surgical outcome of this disease. Methods The clinical data of 29 patients with apical muscular VSD of Fuwai hospital through Jan. 1999 to July 2004 were analyzed retrospectively. The apical VSDwere repaired via 4 different approaches： right atrium, apical right ventriculotomy, apical left ventriculotomy and the incision of the outflow tract of right ventricle combined with apical left ventriculotomy. The operative outcomes between different approaches were analyzed and compared. Results There were 2 perioperative deaths （6. 9%）. One patient repaired via apical left ventriculotomy died of low cardiac output syndrome, the other died intraoperatively from endocardial fibroelastosis, which was confirmed by myocardial biopsy. There were residual VSD in 4 （13. 8%） patients, who were repaired via the right atrium, which did not necessitate reoperation. Other patients were discharged uneventfully. Follow up was completed {n 11 patients and extended 2 to 34 months, none of the 6 survivors had apical ventricular aneurysms. Conclusions The operative outcome of patients with apical VSD is satisfactory although the incidence of residual VSD is higher. The intraoperative transesophageal echocardiography （TEE） should be performed routinely. Surgical approach should be chosen on the actual site of the VSD at operation. Try to repair the VSD via the right atrium as possible, via the apical right ventrieulotomy if needed and try to avoid left ventriculotomy.
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.
ObjectiveTo compare early clinical outcomes between systemic-pulmonary shunts (SPS) and right ventricular to pulmonary artery connection (RV-PA connection) for patients with pulmonary atresia and ventricular septal defect (PA/VSD), and investigate early management strategies for these 2 different palliative procedures.
MethodsWe retrospectively analyzed clinical data of 89 PA/VSD patients who underwent SPS or RV-PA connection in Fu Wai Hospital from January 2009 to December 2011. According to different surgical procedures, all the 89 patients were divided into 2 groups. In SPS group, there were 59 patients including 35 males and 24 females with their median age of 25 months (4 months to 8 years). In RV-PA connection group, there were 30 patients including 19 males and 11 females with their median age of 24 months (28 days to 7 years and 2 months). Early clinical outcomes including mechanical ventilation time, length of ICU stay, morbidity, reexploration, improvement of oxygen saturation (SO2) and mortality were compared between the 2 groups.
ResultsAmong 59 patients in SPS group, 3 patients (5.1%) died postoperatively. There was no in-hospital death among 30 patients in RV-PA connection group. The improvement of percentage of SO2 of RV-PA connection group was significantly higher than that of SPS group (31.7% vs. 22.2%, P < 0.05). There was no statistical difference in length of ICU stay (3.6±2.5 days vs. 4.2±5.1 days, P > 0.05), mechanical ventilation time (34.8±33.5 hours vs. 44.3±39.6 hours, P > 0.05), postoperative morbidity (37.3% vs. 30.0%, P > 0.05) or reexploration rate (15.3% vs. 6.7%, P > 0.05) between SPS group and RV-PA connection group. Incidence of serious postoperative complications of SPS group was signi-ficantly higher than that of RV-PA connection group (25.4% vs. 6.7%, P < 0.05).
ConclusionEarly clinical outcomes of RV-PA connection is better than SPS for PA/VSD patients including greater SO2 improvement and lower mortality. Mid-term and long-term clinical results as well as larger study samples are needed for better evaluation.
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.
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 To investigate the effect of surgical treatment on ventricular septal defect （VSD） in infants under 6kg weight, including the operative indication, surgical techniques and perioperative therapy. Methods All clinical data of 148 consecutive infants under 6kg weight with VSD were collected and studied retrospectively. The infants, age was 1-13（mean 5.3） months with the body weight of 3.5-6.0 （mean 5.3） kg. VSD was perimembranous in 105 cases, subpulmonary in 25, muscular inlet tract in 8, muscular outlet tract 9, and muscular trabecular in 1 case. Other associated cardiac abnormalities included atrial septal defect in 39, patent ducts arteriosus in 17, insufficiency of mitral valve in 9 and moderate to severe pulmonary hypertension in 52. The operations were performed under cardiopulmonary bypass at moderate to low flow, moderate hypothermia and cold crystalloid cardioplegia. Patch repair was used in 85, direct sutures in 63 and 23 cases repaired with partial sternal incision and beating heart. Results The hospital mortality was 4. 1% （6/148）, the causes of death were severe pulmonary hypertention in 2, aortic arch interruption in 2, severe malnutrition in 1 and poor result of mitral valvuloplasty in 1. Other major operative complications included residual shunts （1- 2mm） in 2, and Ⅲ° A-V block in 2, who recoveried 5 days after the operation. The hospital stay was 6 15 （mean 8） days. Follow-up was complete in all 142 survived cases for 4 months-6 years. Two residual shunts healed in first year after the cardiac operation, others recovery smoothly, and are developing well. Conclusion With the improvement of the surgical techniques, the surgical treatment for VSD in infants with low weight is safe and effective, and it is also essential to further improve the effects of surgical treatment in VSD associated with complex abnormalities.
ObjectiveTo evaluate the mid-term outcomes between tricuspid valve detachment (TVD) and non-detachment (NTVD) for ventricular septal defect (VSD).Methods The patients who underwent perimembranous VSD repair in the Department of Cardiovascular Surgery, West China Hospital from 2015 to 2020 were included. According to the surgical method, the patients were divided into a TVD group and a NTVD group. The clinical data of the two groups were compared.Results Totally 538 patients were included in the study. There were 240 patients in the TVD group, including 121 males and 119 females, with an average age of 3.85±8.42 years and an average weight of 14.12±12.97 kg. There were 298 patients in the NTVD group, including 149 males and 149 females, with an average age of 4.42±9.36 years and an average weight of 14.87±12.51 kg. There was no statistical difference in the age, weight, sex, preoperative New York Heart Association (NYHA) classification or tricuspid regurgitation (TR) degree between the two groups (P＞0.05). Median follow-up was 30 (23, 40) months in the TVD group, and 29 (23, 41) months in the NTVD group (P=0.600). After operation, one patient in each group developed third-degree atrioventricular block and recovered to sinus rhythm before discharge (P=0.848). No pacemaker was needed. There was no statistical difference in the length of stay (P=0.054), mortality (P=1.000), in-hospital reoperation (P=0.199), or follow-up reoperation (P=0.505). More than 98% of patients in both groups had postoperative TR less than moderate (P=0.926). At the last follow-up, only 7 (2.9%) patients in the TVD group were detected trivial residual shunting, and 14 (4.7%) in the NTVD group (P=0.289). No one needed to have reoperation because of residual VSD. The TVD group showed less TR during the follow-up (P=0.019).Conclusion TVD is an alternative technique which can be safely used in the closure of VSD, especially in technologically mature medical center. Appropriate tricuspid valve detachment for those hard-to-expose VSDs does not result in poorer tricuspid valve function or higher risk of atrioventricular block, and might reduce the incidence of residual shunting.
ObjectiveTo analyze perioperative prognostic factors of pediatric patients undergoing surgical correction of ventricular septal defect (VSD)and severe pulmonary arterial hypertension (PAH).
MethodsForty pediatric patients with VSD and severe PAH (mean pulmonary artery pressure (PAPm) < 50 mm Hg)who underwent surgical repair in Beijing Anzhen Hospital from 2004 to 2012 were included in the study. There were 21 male and 19 female patients with their age of 7.2±3.3 years and body weight of 19.6±7.1 kg. All the patients were randomly divided into 2 groups:Group Ⅰ (Group=0, n=20, M/F:12/8, continuous nitroglycerin administration via central venous catheter (CVC)and GroupⅡ (Group=1, n=20, M/F:9/11, continuous prostaglandin E1 (PGE1)administration via CVC). The duration of intubation (Tintubation)was used as the dependent variable (Y). Patient age, cardiopulmonary bypass time (TCPB), postoperative PAPm, pulmonary vascular resistance index (PVRI), systemic to pulmonary pressure ratio (Ps/p), Group, left ventricular stroke work index (LVSWI)and right ventricular stroke work index (RVSWI)were used as independent variables (X). Multivariate liner regression analysis model was used to evaluate the influence of X on Y.
ResultsThere was no perioperative death or severe complication in this group. Perioperative prognostic factors of pediatric patients undergoing surgical correction of VSD and severe PAH included group[x1, P=0.004, 95% CI (-71, -16)], TCPB[x2, P=0.011, 95% CI (0.9, 5.8)], posto-perative PAPm (x3, P=0.004 with 95% CI 3.2 to 13.3), RVSWI (x4, P=0.003 with 95% CI-16.9 to-4.3)and PVRI (x5, P=0.03 with 95% CI-0.29 to-0.02). The standardized regression equation was:Y=-0.60x1+0.54x2+2.22x3-1.70x4-0.15x5.
ConclusionPGE1 administration, TCPB, postoperative PAPm, RVSWI and PVRI are predominant perioperative prognostic factors of pediatric patients undergoing surgical correction of VSD and severe PAH.
Objective
To compare the effects of transthoracic device closure and surgical closure on ventricular septal defect systemically.
Methods
A systematic literature search was conducted using the PubMed, EMbase, The Cochrane Library, VIP, CNKI, CBM, Chinese Clinical Trial Register, ClinicalTrials. gov and Wanfang Database up to July 31, 2016. Quality was assessed and data of included articles were extracted. The meta-analysis was conducted using RevMan 5.0 and Stata 14.0 software.
Results
Eleven studies were identified, including 5 RCTs and 6 cohort studies involving 2 504 patients. For success rate, there was no statistical difference between the transthoracic closure group and the surgical closure group in RCT (RR=0.99, 95%CI 0.96 to 1.03, P=0.70); the success rate in the transthoracic closure group was lower than that in the surgical closure group in the cohort study (OR=0.21, 95%CI 0.08 to 0.55, P=0.002). Both results of RCTs and cohort studies showed that compared with surgical closure, transthoracic device closure reduced duration of the operation (RCT MD=–79.38, 95%CI –95.00 to –63.76, P<0.000 01; cohort studyMD=–66.26, 95%CI –71.20 to –61.31, P<0.000 01) and hospital stay (RCTMD=–2.10, 95%CI –2.65 to –1.55, P<0.000 01; cohort studyMD=–3.99, 95%CI –6.03 to –1.94, P=0.000 1), and the patients with blood transfusion (RCT RR= 0.04, 95%CI 0.01 to 0.11, P<0.000 01; cohort studyOR=0.01, 95%CI 0.00 to 0.13, P=0.001). In the transthoracic closure group the risk of postoperative arrhythmia reduced (RCT RR=0.20, 95%CI 0.13 to 0.32, P<0.000 01; cohort studyOR=0.46, 95%CI 0.31 to 0.67, P<0.000 1). In the transthoracic closure group a higher postoperative valvular regurgitation risk in RCT induced (RR=1.45, 95%CI 1.07 to 1.96, P=0.02) and the rate of postoperative valvular regurgitation in cohort study reduced (OR=0.43, 95%CI 0.20 to 0.92, P=0.03). However, there was no statistical difference in postoperative residual shunt (RCT RR=0.96, 95%CI 0.57 to 1.62, P=0.89; cohort study OR=0.52, 95%CI 0.12 to 2.25, P=0.38).
Conclusion
Transthoracic device closure can shorten duration of the operation, hospital stay and reduce the patients with blood transfusion and post- and intraoperative arrhythmia risk. Therefore, transthoracic device closure may be a better approach for some ventricular septal defect patients.
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.
