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．
ObjectiveTo evaluate clinical results of left ventricular retraining followed by double switch operation (DSO) for patients with congenitally corrected transposition of the great arteries (CCTGA) and a deconditioned morphologically left ventricle (mLV).
MethodsClinical data of 14 patients with CCTGA and a deconditioned mLV who underwent surgical therapy in Fu Wai Hospital from May 2005 to May 2011 were retrospectively analyzed. There were 8 male and 6 female patients with their age of 2.5-72.0 (34.4±24.0) months and body weight of 5.1-23.0 (12.7±4.9) kg. Preoperative diagnosis was confirmed by echocardiography, angiography or cardiac catheterization. Major concomitant anomalies included tricuspid regurgitation (TR) in 13 patients, restrictive ventricular septal defect in 10 patients, atrial septal defect or patent foramen ovale in 7 patients, mild pulmonary valve stenosis in 4 patients, patent ductus arteriosus in 4 patients, and third-degree atrioventricular block in 1 patient. All the patients underwent first-stage morphologic left ventricular retraining under general anesthesia followed by second-stage atrial switch and arterial switch operations (DSO) under cardiopulmonary bypass with the interval of 0.67-34.0(10.23±9.47)months.
ResultsAfter the first-stage morphologic left ventricular retraining, there was no postoperative complication or death. During follow-up, mLV end-diastolic diameter (mLVEDd) and posterior wall thickness of mLV were significantly larger than preoperative parameters (P < 0.05). The interventricular septum moved partially towards morphologically right ventricle (mRV). TR degree was significantly decreased, the pressure gradient across the pulmonary artery band was significantly increased (P < 0.05), and left ventricular ejection fraction (LVEF) was not statistically different from preoperative LVEF. And mLV/mRV pressure ratio was significantly increased (P < 0.05). After the second-stage DSO, 2 patients died with the in-hospital mortality of 14.3% (2/14). The causes of death included serious arrhythmia, circulatory collapse and sudden death. Early postoperative complications included pulmonary infection in 6 patients, atrial arrhythmias in 2 patients, pleural effusion in 2 patients, pneumothorax in 1 patient, diaphragmatic paralysis cured by diaphragm placation in 1 patient, respiratory tract hemorrhage in 1 patient, mild aortic insufficiency in 1 patient, peritoneal dialysis for 1 patient, extracorporeal membrane oxygenation for 1 patient, and tracheal intubation for a second time for 1 patient. All the 12 patients who were discharged alive were followed up for 2 to 8 years. One patient died during follow-up with the late mortality of 8.33% (1/12), and the cause of death was serious arrhythmia and circulatory collapse. Eight patients were in New York Heart Association (NYHA) classⅠ, and 3 patients were in NYHA class Ⅱ. Major late complications included left ventricular dysfunction in 3 patients, moderate aortic valve regurgitation in 3 patients, and moderate mitral valve regurgitation in 1 patient.
ConclusionShort-term clinical results of left ventricular retraining followed by DSO for patients with CCTGA and a deconditioned mLV are satisfactory, and its middleand long-term results need further follow-up. But postoperative left ventricular dysfunction and new-onset aortic valve regurgitation deserve more attention.
Objective To review and summarize the clinical outcomes of neonatal D-transposition of the great arteries by rapid two-stage arterial switch operation. Methods Between September 2002 and May 2003, five neonates with D-transposition of the great arteries were repaired by rapid two-stage arterial switch operation. The operative age was 83.0±72.2 day and weight was 4.7±0.9 kg. Because these patients came to the hospital late, the left ventricle was unable to accommodate the systemic pressure, so the left ventricle had to be prepared by pulmonary artery banding and systemic-pulmonary arterial shunt. After 6-9 days, the arterial switch procedure was performed. Results At first stage, one patient died of supraventricular tachycardia and oliguria after peritoneal dialysis. Four patients were repaired by arterial switch operation with no death. These patients were followed up for 2 to 10 months and had good development. The echocardiogram showed that there were no intracardiac residual shunt , the aorta and pulmonary artery anastomosis had no obstruction . The heart function was good, ejection fraction 0.68-0.77,fractional shortening 0.24-0.37. One patient had mild aortic valve regurgitation. Conclusion Rapid two-stage arterial switch operation is the best way for neonatal D-transposition of the great arteries that the left ventricle was unable to accommodate the systemic pressure.
Objective To evaluate and compare the efficacy of anterior subcutaneous and submuscular transposition of the ulnar nerve in treating cubital tunnel syndrome. Methods From August 2006 to August 2008, 66 patients with cubital tunnel syndrome were treated with anterior subcutaneous transposition (subcutaneous group, 24 cases) and with anterior submuscular transposition (submuscular group, 42 cases). According to McGowan stages, all patients were at Stage2 or 3 entrapment neuropathy with paresthesia in the ring and small fingers. Respectively, 3 cases and 8 cases compl icated by interosseous muscle atrophy in subcutaneous group and in submuscular group. No significant difference was found in gender, age, duration of the disease, and compl ication between two groups (P lt; 0.05). The surgical features, distribution of Bishop rates, two-point discrimination test, muscular strength, and compl ications were recorded. Results The operation time was (28.4 ± 5.2) minutes in subcutaneous group and (43.8 ± 5.6) minutes in submuscular group, showing significant difference (P lt; 0.01). The incision length was (12.2 ± 2.5) cm in subcutaneous group and (13.6 ± 2.8) cm in submuscular group, showing significant difference (P lt; 0.05). All patients were followed up 1-3 years. According to Bishop scoring system, the results were excellent in 18 cases, good in 4 cases, and poor in 2 cases in subcutaneous group; excellent in 36 cases, good in 3 cases, and poor in 3 cases in submuscular group; and showing no significant difference between two groups (P gt; 0.05). At 6 months postoperatively, twopoint discrimination and grip strength were improved when compared with that of preoperation (P lt; 0.05), but there was no significant difference between two groups (P gt; 0.05). Pain and dysesthesia of the scar were noted in 1 patient of the subcutaneous group and 3 patients of the submuscular group. No infection or hematoma was found and no patient needed reoperation. Conclusion Both operative methods are effective alternative for treating cubital tunnel syndrome. The anterior ubcutaneous anterior transposition of the ulnar nerve has fewer traumas, and it is a better choice for some old patients.
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.
Objective To observe the result of reconstructing quadriceps femoris function in the paraplegia rats by using the 7th cervical nerve root (C7) transposition with autologous and allogeneic neural transplantation. Methods Twenty16-week-old SPF male Wistar rats were adopted to prepare frozen sciatic nerve. Thirty-six Wistar rats were divided into 2 groups (group A and group B, n=18). The left paraplegia model was establ ished with left spinal cord hemisection by the micro scissors under the operation microscope. After the model establ ishment, the homolateral autologous sciatic nerve was bridged with the femoral nerve root by the translocation of C7 in group A, while the allogeneic sciatic nerve was bridged with the femoral nerve root by the translocation of C7 in group B. At 16 weeks and 24 weeks after operation, 9 rats in each group were selected for the neuroelectric-physiological test and then the histomorphology of the nerves was observed under the microscope and the electron microscope. The fresh weight recovery rate of quadriceps femoris was calculated. Results At 16 and 24 weeks after operation, the nerve action-evoked potential (NAP) was (1.14 ± 0.07) mV and (1.21 ± 0.07) mV in group A, and (0.87 ± 0.06) mV and (0.99 ± 0.05) mV in group B; the nerve conduction velocity (NCV) was (17.34 ± 2.15) m/s and (19.00 ± 3.02) m/s in group A, and (11.23 ± 1.45) m/s and (12.54 ± 1.59) m/s in group B, respectively, indicating significant differences (P lt; 0.05) between 2 groups. At 16 and 24 weeks after operation, HE staining and Bielschowsky staining showed that group A had a large number of nerve fiber regeneration, with a regular arrange of axons; while group B had l ittle nerve fiber regeneration with a scattered arrange of axons. At 24 weeks after operation, images in TEM showed a large number of regeneration myel inated nerve fibers and a small number of unmyel inated nerve fibers through the transplanted nerve in two groups. At 16 weeks after operation, the number of myel inated nerve fibers in group A and group B was (438 ± 79) and (196 ± 31) / vision, the areas of myel inated nerve fiberswere (5 596.00 ± 583.94) and (4 022.63 ± 615.75) μm2 / vision; after 24 weeks, the number of myel inated nerve fibers in groups A and B were (642 ± 64) and (321 ± 75)/vision, the areas of myel inated nerve fibers were (6 689.50 ± 1 142.10) and ( 4 733.00 ± 982.22) μm2/vision, indicating significant differences between two groups (P lt; 0.05). There was no statistically significant difference (P gt; 0.05) in the wet weight recovery rate of quadriceps between group A and group B at 16 weeks (87.96% ± 4.93% vs. 86.47% ± 7.47%) and at 24 weeks after operation (90.10% ± 4.22% vs. 87.66% ± 3.14%). Conclusion C7 transposition combined with autograft and allograft of sciatic nerve can reconstruct the partial function of the quadriceps femoris in paraplegia rats. The effect of graft is better than that of graft obviously.
OBJECTIVE: To investigate the repairing result for the massive bony defects of upper and middle tibia and lower femur. METHODS: Since 1974, four types of pedicled-fibula transposition were performed to repair the massive bone defect of tibia and femur in 25 cases, which included; 9 cases with benign tumor of upper part of tibia were performed muscle-pedicled fibula transposition and knee fusion after tumor resection; 9 cases with extensive benign tumor or tumoroid lesion of tibia shaft were performed muscle-pedicled fibula transposition and tibia-fibula fusion after tumor resection; 2 cases with extensive benign tumor or tumoroid lesion of middle and lower parts of tibia were performed vascular pedicled fibula transposition and tibia-fibula fusion; 5 cases with benign tumor of distal femur were performed vascular pedicled fibula reversal transposition and knee fusion. RESULTS: After 3 months to 11 years follow-up, 23 cases showed bone healing at 6 months postoperatively. The other 2 cases showed bone healing at 12 months postoperatively. All cases had satisfactory functional rehabilitation. CONCLUSION: Pedicled-fibula transposition is a choice method for repairing massive defects of tibia and femur.
ObjectiveTo evaluate the methods and effectiveness of contralateral C7 nerve root and multiple nerves transfer for the treatment of brachial plexus root avulsion.
MethodsBetween June 2006 and June 2010, 23 patients with brachial plexus root avulsion were treated. There were 20 males and 3 females, aged 17 to 42 years (mean, 27.4 years). The time from injury to operation was 4 to 12 months (mean, 5.9 months). In 16 patients having no associated injury, the first stage procedure of contralateral C7 nerve root transfer and accessory nerve transfer to suprascapular nerve or phrenic nerve transfer to anterior upper trunk was performed, and the second stage procedure of the contralateral C7 nerve root transfer to median nerve and intercostal nerve transfer to axillary nerve was performed. In 4 patients having phrenic nerve and accessory nerve injuries, the first stage procedure of the contralateral C7 nerve root transfer and second stage procedure of the contralateral C7 nerve root transfer to median nerve and musculocutaneous nerve were performed. In 3 patients having hemothorax, pneumothorax, and rib fractures, the first stage procedure of the contralateral C7 nerve root transfer and accessory nerve transfer to suprascapular nerve, and the second stage procedure of the contralateral C7 nerve root transfer to median nerve and musculocutaneous nerve were performed. The British Medical Research Council (MRC) sensory grading (S0-S4) and modified muscle strength grading standard (M0-M5) were used for comprehensive assessment of limb and shoulder abduction, elbow/biceps muscle strength, flexor wrist and finger muscle strength and median nerve sensory recovery.
ResultsTwenty-three patients were followed up 3-4.5 years (mean, 3.4 years). At 3 years after operation, the shoulder abduction reached 0-82°(mean, 44°). In 16 patients having no associated injuries, the shoulder abduction was more than 30°in 13 cases, and was more than 60°in 3 cases; in 3 patients having hemothorax, pneumothorax, and rib fractures, the shoulder abduction was more than 30°; and in 4 patients having phrenic nerve and accessory nerve injuries, the shoulder abduction was 0°. The muscle strength of elbow/biceps was M3 or more than M3 in 9 cases, was M1-M2 in 8 cases, and was M0 in 6 cases; the muscle strength of flexor wrist or finger was M3 or more than M3 in 7 cases, was M1-M2 in 11 cases, and was M0 in 5 cases. Median nerve sensory recovery was S3 or more than S3 in 11 cases, was S1-S2 in 7 cases, and was S0 in 5 cases. After 3 years, affected limb had locomotor activity in 11 patients, affected limb had activities driven by the contralateral latissimus dorsi muscle contraction in 12 patients.
ConclusionContralateral C7 nerve root and multiple nerves transfer is a good method to treat brachial plexus root avulsion.
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 evaluate the short- and middle-term outcomes of surgical treatment for distal aortic arch lesions using stented elephant trunk implantation combined with transposition of left subclavian artery to left common carotid artery.
Methods
The clinical data of 14 patients with distal aortic arch lesions undergoing stented elephant trunk procedure with left subclavain artery transposition under hypothermic cardiopulmonary bypass (CPB) with antegrade selective cerebral perfusion from May 2009 to November 2015 in our hospital were retrospectively reviewed. All of them were males with a mean age of 52±14 years ranging from 20 to 69 years. Hypertension was observed in nine patients, coronary artery disease in five and prior cerebral infarction in one. History of percutaneous coronary intervention was noted in one patient, history of Bentall operation in one, ligation of patent ductus arteriosus in one and endovascular aneurysm repair in one.
Results
There was no hospital death. Concomitant procedures included coronary artery bypass grafting in two patients and plasty of the ascending aorta replacement in one. Mean duration of mechanical ventilation and ICU stay was 21±7 h and 43±19 h, respectively. All patients survived and were discharged. One patient was lost to follow-up and no patient died during the follow-up. Postoperative computed tomography revealed good patency of the anastomotic site between the left subclavian artery and the left common carotid artery.
Conclusion
Stented elephant trunk procedure with left subclavain artery transposition obtains satisfactory surgical results in patients with distal aortic arch lesions.
