目的 總結單心室瓣膜反流的外科治療經驗，觀察治療效果。 方法 回顧性分析2006年7月至2012年1月上海交通大學醫學院附屬新華醫院61例單心室患者的臨床資料，其中男36例，女25例；手術年齡2個月至 20歲；體重2～58 kg。右心室型41例，左心室型13例，未定型型7例。根據瓣膜反流程度不同分為3組，無/微量反流組：28例，瓣膜未行處理；輕/中度反流組：21例，瓣膜未行處理；重度反流組：12例，手術同期行瓣膜成形。收集所有患者住院及隨訪資料，分析輕/中度反流組、重度反流組瓣膜反流變化趨勢，以及影響瓣膜反流的因素。結果 住院死亡5例，住院死亡率8.2% （5/61）。重度反流組患者行瓣膜成形術后反流程度較術前明顯減輕（由術前4.00級下降至術后2.08級）。隨訪56例，隨訪時間6～38個月，重度反流組隨訪10例，隨訪期間死亡2例，其余8例中重度反流2例，中度反流3例，輕度反流2例，微量反流1例；瓣膜反流程度增加趨勢明顯（由術后平均2.08級增加至平均2.75級）。輕/中度反流組隨訪19例，隨訪中無死亡，其中反流程度增加至重度3例（原1例輕度反流，2例中度反流），反流程度由輕度增加至中度3例，瓣膜反流程度由術后平均2.33級增加為平均2.58級。輕/中度反流組瓣膜反流增加率與無/輕微反流組比較差異無統計學意義（瓣膜反流增加率為31.5% vs. 19.2%，χ2=0.36，P=0.55）。單因素分析結果顯示，瓣膜反流增加者在隨訪過程中心功能較瓣膜反流無變化或減輕者明顯降低（術后左心室射血分數53.11%±5.61% vs. 59.65%±3.32%，t =-5.49，P=0.00），而左心室舒張期末容積較瓣膜反流無變化或減輕者明顯增加（t =2.58，P=0.01）。 結論 單心室合并重度瓣膜反流行瓣膜成形術近期效果較好，但隨著心功能下降、心室擴張，瓣膜反流程度加重趨勢明顯；輕/中度瓣膜反流可暫不進行處理，但部分患者瓣膜反流有增加趨勢，提示應注重術后隨訪。
ObjectiveTo summarize the experience of right ventricular outflow tract reconstruction with self-made single-valve conduit for the treatment of complex congenital heart disease, and to explore the key points of operation, and to evaluate the short-term and medium-term results of the treatment.MethodsWe retrospectively analyzed the clinical data of 65 patients with complex congenital heart disease treated by self-made single-valve conduit from January 2006 to June 2018. There were 42 males and 23 females aged 5-23 (9.9±4.2) years with weight 15-65 (26.2±9.9) kg. There were 19 patients with single valve artificial blood vessel (an artificial vascular group), and 46 patients with single valve bovine pericardium tube (a bovine pericardial tube group). There were 48 patients of ventricular septal defect (VSD) with pulmonary atresia (PA), 10 patients of corrective transposition of great artery with pulmonary artery stenosis, 5 patients of tetralogy of Fallot with single coronary artery malformation, 2 patients of double outlet of right ventricle with pulmonary artery stenosis and single coronary artery malformation.ResultsTwo patients died early after operation, both of them were VSD/PA patients who underwent radical treatment of extravascular prosthesis. The right ventricular outflow tract pressure difference was 13-37 (25.2±4.9) mm Hg in the artificial vascular group and 5-23 (10.5±3.3) mm Hg in the bovine pericardial tube group. No obvious reflux was found at discharge. The patients were followed up for 8 months to 13 years. One patient was lost. During the follow-up period, there were 5 patients of moderate tricuspid regurgitation, 32 patients of moderate intraductal regurgitation, 7 patients of severe right ventricular outflow tract obstruction, 11 patients of moderate obstruction and 25 patients of mild obstruction. There was no late death. Heart function classification of all patients was in New York Heart Association classⅠtoⅡ.ConclusionThe self-made single-valve conduit used to reconstruct right ventricular outflow tract shows good clinical effect. Using bovine pericardium tube has less pressure difference of outflow tract in comparison with artificial blood vessel. Bovine pericardium tube is more recommended for young and low weight patients.
Objective To investigate the surgery experience of modified intra/extracardiac conduit total cavopulmonary connection (TCPC). Methods We retrospectively analyzed clinical data of 47 patients of complex congenital heart disease undergoing intra/extracardiac conduit total cavopulmonary connection in our hospital between January 2008 and December 2015. There were 29 males and 18 females with a median age of 7 years (range 4 to 9 years) and median body weight of 22 kg (range 14 to 38 kg). The heart echocardiography and cardiac imaging confirmed diagnosis suitable for TCPC surgery. Results There was no early death in the whole group. The mean pulmonary arterial pressure was 16 (12–20) mm Hg and the ventilation time was 14 (7–97) h. The main complications were intractable pleural effusion in 7 patients, low cardiac output syndrome in 3 patients, repeated supraventricular tachycardia in 1 patient. All the patients recovered after treatment. At the end of discharge, the percutaneous oxygen saturation was 85%–96% (92.6%±3.3%). The echocardiography showed the conduit pressure was 0–2 mm Hg. Patients were followed up for 1 to 7 years. Three patients were lost. One patient had intestinal nutrition loss, receving repeated pleural effusion, the treatment was ineffective, died after 4 years. Four patients of repeated pleural effusion improved after treatment. One patient repeated attacks supraventricular tachycardia within 1 year, controlled by amiodaronum, already stopped about 28 months. No recurrence occurred. All survivors were in New York Heart Association (NYHA) functional class Ⅰ or Ⅱ, with good activity tolerance. Conclusion The modified intra/extracardiac conduit TCPC combines the advantages of both the lateral tunnel and the extracardiac conduit. The operation is simple, used in the treatment of complex congenital heart disease. The short-term and mid-term results are encouraging.
Objective To investigate the perioperative change and the predictive value of myoglobin, creatine kinase-MB (CK-MB), and cardiac troponin I (cTnI) in non-coronary cardiac surgery. Methods The clinical data of 77 patients undergoing cardiac surgery for non-coronary lesions in the Shanghai Xinhua Hospital from March 2016 to November 2016 were retrospectively reviewed, including 37 males and 40 females with a median age of 2 years. There were simple congenital heart diseases in 45 patients, complicated congenital heart diseases in 10, and heart valve diseases in 22. The levels of myoglobin, CK-MB and cTnI were collected at the first postoperative day. The ventilation duration and the length of ICU stay were recorded. The recovery condition was accessed by senior surgeons. Results The myoglobin, CK-MB and cTnI concentrations increased at the first postoperative day, and cTnI increased most significantly. The multivariate linear regression analysis indicated that these changes were only related to cardiopulmonary bypass time and aortic cross-clamping time (P<0.001). The high cTnI level was associated with prolonged ventilation duration and length of ICU stay. Fourteen patients (18.2%) did not recovered well, and their cTnI level was significantly higher than that of well-recovered patients (16.8±16.7 ng/mlvs. 5.1±4.4 ng/ml,P<0.001). The cTnI cutoff value of 5.33 ng/ml could predict whether patients had good postoperative recovery (area under the receiver operating characteristic curve=0.862,P<0.001), and the predictive value of cTnI was superior to that of myoglobin and CK-MB. Conclusion The increase levels of myoglobin, CK-MB and cTnI post non-coronary cardiac surgery are associated with prolonged cardiopulmonary bypass time and aortic cross-clamping time. cTnI on postoperative 24 h may predict good recovery, and it is a useful biomarker.
Objective To analyze the mid-term results of surgical treatment for prosthetic valve endocarditis (PVE). Methods We retrospectively analyzed the clinical data of 22 PVE patients operated in our institution from January 2006 to June 2016. There were 14 males and 8 females, aged 31-62 (49.6±11.8) years. PVE occurred following single valve replacements in 20 patients, including aortic valve replacements in 12 and mitral valve replacements in 8. Two patients suffered PVE after multi-valve replacement, which was aortic and mitral valves. Mechanical valves were used in all patients. Early PVE (<1 year after valve implantation) was detected in 10 patients, and late PVE (>1 year after valve implantation) in 12 patients. Blood culture was negative in 6 patients. Fifteen patients underwent emergent or urgent surgery (within one week after definite diagnosis) and 7 elective surgery. Paravalvular abscess was detected in 12 patients and repaired bovine pericardium. Results Three patients (13.6%) died postoperatively in hospital, among whom two died of multiple systemic organ failure, and the other died of cerebral hemorrhage. Main postoperative complications included low cardiac output syndrome in 5 patients (22.7%), renal dysfunction in 6 (27.3%), respiratory failure in 5 (22.7%) and pulmonary infection in 4 (18.2%). During the follow-up of 6-120 (53.6±20.8) months, 2 deaths were observed in the middle term, including one sudden death and the other of cerebral infarction. No recurrent infection or valve-related surgery was observed during the follow-up. The survival rate was 86.4% in 1 year and 70.4% in 5 years. Conclusion PVE is a very severe disease with high mortality. Early surgical treatment and complete removal of infectious tissues have preferable early- and mid-term results.
ObjectiveTo investigate the results of emergent aortic arch replacement using moderate hypothermic circulatory arrest and unilateral antegrade cerebral perfusion (MHCA+UACP).MethodsWe retrospectively analyzed the clinical data of 146 patients who underwent emergent aortic arch replacement using MHCA+UACP in our institution from January 2008 to June 2018. There were 111 males and 35 females aged 60.3±7.2 years. According to different surgical approaches, patients were divided into two groups: a total arch replacement (TAR) group (n=104) and a semi arch replacement (SAR) group (n=42). Right axillary artery was cannulated for cardiopulmonary bypass (CPB) and cerebral perfusion. Core temperature at the onset of MHCA was 23.4±1.4 ℃. UACP was initiated at 18-22 ℃ with the flow of 5-10 ml/(kg·min). Flow was adjusted to maintain cerebral perfusion pressure of 50–60 mm Hg.ResultsCPB time was 235.0±42.0 min. Aortic clamp time was 154.0±29.0 min. Circulatory arrest (CA) time was 48.1±13.0 min. The CPB time and CA time of the TAR group were longer than those of SAR group. Overall mortality rate was 9.6%. Complications included permanent neurological dysfunction (PND), temporary neurological dysfunction (TND), acute kidney injury (AKI) requiring dialysis and delayed extubation (mechanical ventilation time >72 hours). Overall incidence of PND and TND was 2.7% and 6.8%, respectively. The incidence of AKI requiring dialysis was 4.1%. The incidence of delayed extubation was 21.9%. No difference of mortality rate or incidence of complications was found between the two groups. The average follow-up was 63.0±33.1 months. The 5-year survival rate was 72.6% in the TAR group and 85.5% in the SAR group.ConclusionEmergent aortic arch replacement using MHCA+UACP can be accomplished with excellent results.