室间隔缺损两种补片修补的术后残余漏比较

目的：比较室间隔缺损两种补片方法的残余漏状况。方法：113例室间隔修补采用自体心包片修补，另80例室间隔采用涤纶布补片修补。结果：残余漏发生率：涤纶组6％（5／18），自体心包片组3．5％。结论：室间隔修补材料以自体心包片为佳。     

416例室间隔缺损的外科治疗

目的 探讨室间隔缺损(VSD)手术时机、修补方法及补片材料的选择.方法 在低温体外循环下连续手术治疗VSD 416例,其中男257例,女159例;年龄40天～46岁,平均4.7±3.4岁,其中婴幼儿235例(56.5%);体重3～80kg,平均14.6±11.5kg,10kg以下者187例(45%).直视缝合307例,新鲜自体心包片修补64例,涤纶片修补44例,毡片修补1例,补片修补均采用全周连续缝合;隔瓣后缺损显露不清楚者,可切开隔瓣或切断园锥乳头肌.结果 术后30天内死亡6例(1.4%),主要并发症发生率8.4%.结论(1)VSD手术时机主张“三早”原则,即早发现、早诊断、早治疗.(2)正确地选择心脏切口,补片以全周连续缝合可节省手术时间,减少残余漏,即使不做超越或转移缝合也能避免Ⅲ°房室传导阻滞.(3)新鲜自体心包片是修补VSD的良好材料.     

应用自体心包瓣膜成型

目的 探讨应用自体心包进行心脏二尖瓣、三尖瓣瓣膜成型的技术特点和可行性,评价其术后效果.方法 2005年1月至2006年6月我院采用自体心包成型心脏瓣膜6例,其中男性4例,女性2例.先天性心脏病室间隔缺损合并感染性心内膜炎致三尖瓣关闭不全2例,致二尖瓣关闭不全1例;黏液变性二尖瓣关闭不全3例.4例二尖瓣病变采用了双孔成形技术,同时用自体心包片制作成形环,替代人造瓣环或自体心包片修补后叶.2例三尖瓣病变用自体心包片修补三尖瓣前瓣叶以及隔瓣,瓣环再行De vaga环缩.结果 6例患者均顺利出院,随访3个月.术后患者二尖瓣、三尖瓣反流程度均有明显改善(P＜0.05),心功能均有明显提高(P＜0.05).结论 自体心包材料能最大限度地发挥瓣膜成型手术的优势,降低并发症和手术费用,近期效果良好.     

自体心包瓣膜成型术的临床研究

目的探讨应用自体心包进行心脏二尖瓣、三尖瓣瓣膜成型的技术特点和可行性,评价其术后效果.方法2005-01-2006-06我院采用自体心包成型心脏瓣膜6例,其中男性4例,女性2例.先天性心脏病室间隔缺损合并感染性心内膜炎致三尖瓣关闭不全2例,致二尖瓣关闭不全1例;黏液变性二尖瓣关闭不全3例.4例二尖瓣病变采用了双孔成型技术,同时用自体心包片制作成型环,替代人造瓣环或自体心包片修补后叶.2例三尖瓣病变用自体心包片修补三尖瓣前瓣叶以及隔瓣,瓣环再行De vaga环缩.结果6例患者均顺利出院.随访3个月.术后二尖瓣、三尖瓣返流程度均有明显改善(P<0.05).术后患者心功能均有明显提高(P<0.05).结论自体心包材料能最大限度的发挥瓣膜成型手术的优势,降低并发症,降低手术费用,近期效果良好,长期资料有待进一步的随访.     

全胸腔镜心脏手术的并发症及防治分析

目的分析探讨154例全胸腔镜心脏手术并发症。方法在周围体外循环下采用电视胸腔镜完成心脏手术154例,其中房间隔缺损修补术64例,室间隔缺损修补术77例,二尖瓣置换术13例。结果房、室间隔缺损修补术时间为28～132min;二尖瓣置换术为96～157min;整个手术时间为2.6～5.6h,平均为3.6h。术中术后有并发症20例(12.98%),术中扩大切口6例(3.90%),其中横断胸骨3例;术中右室破裂1例,术后二次止血4例(2.60%),肝破裂1例,右小腿骨筋膜室综合征2例,肺部感染2例;室缺残余漏2例,术口逾期愈合2例,全组死亡1例(O.69%)。结论电视胸腔镜下行简单心脏病手术创伤小、手术效果较好,但要求操作医师操作技术熟练。否则在不熟练下操作会增加并发症发生率。     

介入治疗室间隔缺损修补术后残余漏的初步研究

目的:探讨室间隔缺损(VSD)外科修补术后残余漏介入治疗的方法学及临床疗效。方法:对年龄在7～58岁之间的12例VSD修补术后残余漏患者行介入治疗。封堵材料为Amplatzer非对称性室间隔缺损封堵器(AAVSDO)和对称性国产室间隔缺损封堵器(VSDO)。距手术修补时间平均为(10.2±5.5)年;9例为膜部室间隔缺损修补术后患者,3例为法乐四联征(TOF)术后患者;8例修补术后心电图示完全性右束支传导阻滞(CRBBB),1例修补术后出现Ⅲ度房室传导阻滞并安装了永久起搏器。以经食道超声(TEE)或经胸超声(TTE)以及左心室造影测量残余漏大小。9例患者各有1个残余漏口,3例患者右心室面有两个残余漏口。结果:超声及左心室造影所测残余漏直径分别为3～10 mm和4～10 mm,所选用封堵器直径为4～12 mm,封堵15分钟后造影示11例残余漏完全封堵,1例残留少量分流,术后1个月复查时残余分流消失。所有患者未出现新的心律失常及其它并发症。结论:介入治疗室间隔缺损修补术后残余漏安全有效,其远期效果需长期随访观察。     

浅低温心脏跳动下房、室间隔缺损修补术56例临床分析

目的探讨浅低温体外循环心脏跳动下房、室间隔缺损修补术的应用前景.方法应用浅低温心脏跳动下心内直视手术方法,对先天性心脏病房间隔缺损15例及室间隔缺损(室缺)41例患者施行房、室间隔缺损修补术.结果全部患者手术过程顺利,术中未出现心室颤动,术后胸腔引流量少,未发生严重心律失常、低心排血量综合征、空气栓塞等并发症.结论本方法避免了主动脉阻断所引起的心肌缺血、缺氧和再灌注损伤以及心脏局部冰屑及冷停跳液所致的物理性损伤,是一种较接近生理状态的心肌保护法,能较好地保护心肌功能,手术操作简单,能清楚地发现隐匿及多发性室缺,降低残余漏;避免传导系统的损伤;在做好排气措施下,是一种安全可行的方法.     

心脏二次手术的体会(附47例报告)

实施心脏二次手术的心脏病患者47例,行自体瓣膜或机械(生物)瓣切除、单纯二尖瓣置换术19例,二尖瓣并主动脉瓣置换术9例,机械瓣置换瓣周漏行间断缝合修补1例,三尖瓣成形术8例,三尖瓣置换术(生物瓣) 2例,部分房间隔切除并黏液瘤摘除术2例,部分室间隔切除并黏液瘤摘除术1例,法洛四联症根治术后残余漏补片修补2例,因右室流出道梗阻而切除肥大肌束及原右室流出道补片2例,室间隔缺损残余漏补片修补4例、直接修补3例,用右侧桡动脉、大隐静脉行冠脉旁路移植术1例,主动脉弓替换 象鼻手术1例,表浅心脏撕裂伤行缝合修补术3例.二次术后开胸止血2例,死亡2例,余均康复出院.心脏二次手术前应充分改善患者一般情况,术中强调心肌保护及彻底止血,术后使用必要的血管活性药物.     

室间隔缺损术后残余漏的发生原因及处理

回顾1454例室间隔缺损修补术后65例(4.5％)残余漏的发生及转归。其中单纯室间隔缺损(VSD)1152例,术后残余漏38例(3.3％);合并VSD的302例中,法乐氏四联症(TOF)201例,残余漏13例(6.5％)。本组65例残余漏患者中,二次手术修补27例(3例死亡),自行闭合9例,缩小24例,无变化5例。认为室间隔缺损＞8mm者应补片修补,残余缺损＞5mm者宜早期手术治疗,＜5mm者可随访;提高手术技术是预防残余漏发生的关键。     

超声心动图检查继发孔型房间隔缺损封堵术后并发症的诊断价值

目的:研究超声心动图检查继发孔型房间隔缺损封堵术后并发症的应用价值。方法:选取我院2009年7月至2018年7月确诊继发孔型房间隔缺损并行经导管或经胸封堵术的患者3910例,所有患者术前经胸超声心动图(TTE)或经食管超声心动图(TEE)诊断筛选适应证,术中经经胸超声心动图或经食管超声心动图监测,术后复查经胸超声心动图,观察评价封堵器形态位置,评估相关并发症。结果:3910例行房间隔封堵术的患者中,封堵器脱落8例(0.20%),均急诊转外科修补治疗。心脏穿孔/磨蚀事件共8例,其中主动脉窦-右心房瘘1例(0.03%),经皮封堵治疗成功;二尖瓣前叶穿孔2例(0.05%),予随诊观察7年未特殊处理;心脏穿孔或心房壁损伤5例(0.13%),其中1例死亡(0.03%),4例行心包穿刺引流后好转(0.10%)。术后心包积液102例(2.61%),其中8例为少中量-中量心包积液,术后随访无明显变化或有所增多,患者血流动力学稳定,予随诊观察;94例为微量-少量心包积液,随诊观察积液量未见增加。术后残余分流167例(4.27%),其中多发房间隔缺损共102例;另外残余分流束宽度大于等于5 mm共17例,残余分流束小于5 mm或少量分流共150例,复查后分流均减少或消失。结论:房间隔缺损封堵术相关严重并发症包括封堵器脱落、心脏穿孔/磨蚀,发生率极低但危害大,常见并发症包括心包积液和残余分流,发生率低且预后好,超声心动图在及时诊断并发症和随访观察方面起到了不可替代的作用。     

小于4岁先天性心脏病患儿急诊手术41例临床报告

目的 探讨婴幼儿先天性心脏病急诊手术原因及疗效。方法 收集我院外科1998年1月-2000年11月收治的41例小于4岁的患儿资料。分析急诊心脏手术的原因及手术效果。结果 41例患儿中，法鲁四联症25例，房间隔缺损合并肺动脉瓣狭窄5例。完全型肺静脉异位引流4例。大动脉转位2例，室间隔缺损合并肺动脉高压3例。三尖瓣闭锁合并室间隔缺损1例，室间隔缺损合并右室赘生物1例。院内手术死亡7例。死亡率17.1%。结论 病情危重，内科治疗效果不佳的先天性心脏病患儿接受急诊手术治疗，可以取得较好效果。     

Heart malformations in trisomy 13 and trisomy 18]

Congenital heart diseases were studied in children diagnosed of trisomy 13 and trisomy 18 in our hospital between January 1973 and July 1990. Twenty patients with trisomy 18 were diagnosed (18 females and two males). All had cardiac malformations. The findings were: ventricular septal defect in 16 cases (80%), valvular anomalies in 12 (63%), patent ductus arteriosus in nine (47%) and atrial septal defect or patent foramen ovale in 7 cases (36%). We found some complex congenital cardiac diseases: one atrioventricular canal, one tetralogy of Fallot, one hypoplastic left ventricle with mitral atresia and double outlet right ventricle, one case of univentricular heart with aortic outlet from a rudimentary cavity, a right ventricular atresia with pulmonary and tricuspid valves atresia. Nine cases of trisomy 13 were diagnosed (seven females and two males). We found: ventricular septal defect in 7 cases (77%), valvular disease in five (100% of the necropsy studies), secundum atrial septal defect in 4 patients (80%) and patent ductus arteriosus in two. Two cases presented hypoplastic left ventricle with aortic arch hypoplasia, one of them had subaortic stenosis and left superior vena cava being connected to the right atrium via coronary sinus; one case showed fibroelastosis. Our results have been similar to the previously reported and confirm the invariably presence of cardiac malformations in these syndromes. These malformations are an important sign of suspicion in fetal ultrasonography.     

Echo-phonocardiographic and contrast studies in conditions associated with systemic arterial trunk overriding the ventricular septum: truncus arteriosus, tetralogy of Fallot, and pulmonary atresia with ventricular septal defect.

Echocardiography was performed in 62 patients--20 with truncus arteriosus, 14 with tetralogy of Fallot, and 28 with pulmonary atresia with ventricular septal defect. Features common in all three groups were: large single systemic arterial trunk overriding the ventricular septum, mitral-semilunar continuity, large right ventricular dimension, and normal septal motion. Indocyanine green contrast flow patterns were similar and were most helpful in detecting an associated atrial septal defect and in studying the timing and pattern of right-to-left shunting. Echo-phonocardiographic studies revealed that the ejection click coincided with the point of maximal opening of aortic or truncal valve. Left atrial dimension was measured in 55 patients and was normal or small in 41 patients and large in 14 patients. Our observations indicate that left atrial dimension provides a good index of pulmonary flow and can help differentiate those patients with increased pulmonary flow and can help differentiate those patients with increased pulmonary flow (truncus arteriosus) from those patients with reduced pulmonary flow (tetralogy of Fallot and pulmonary atresia with associated ventricular septal defect).     

Surgical experience with congenital heart disease in Down's syndrome

Children with Down's syndrome and congenital heart defects have multiple problems. The role of cardiac surgery in the management of these patients was investigated by reviewing the clinical data, hospital course and follow-up of 21 patients (9 males and 12 females, age range 1 month to 14 years) with Down's syndrome and congenital heart defects operated in our institute. Twelve (57%) of these were infants and nine (43%), older children. Five were in congestive cardiac failure, four were hypothyroid. The heart lesions ranked in incidence as follows: atrioventricular septal defect 7 (33.3%), tetralogy of Fallot 3 (14.3%), tetralogy of Fallot & atrioventricular septal defect both 2 (9.5%), double outlet right ventricle with pulmonary stenosis 1 (4.8%), patent ductus arteriosus 2 (9.5%), patent ductus arteriosus plus coarctation 1 (4.8%), ventricular septal defect 2 (9.5%), atrial septal defect plus ventricular septal defect 1 (4.8%), atrial septal defect plus patent ductus arteriosus plus right pulmonary artery stenosis 1 (4.8%) and transposition of great arteries with multiple ventricular septal defect 1 (4.8%). Four (19%) patients had palliative procedures while the rest (81%) underwent primary repair. All survived the operation. The post-operative period was complicated in 6 (28.5%), with respiratory infections in 3, pulmonary hypertensive crisis in 2 and complete heart block in 1. The early mortality was 0, while there were 2 (9.5%) late deaths. The number of hospitalisations was markedly reduced according to the parents. Follow-up showed near normal pulmonary artery pressure in 50 percent children with large shunts and a good developmental spurt was seen in 60 percent. From a purely surgical viewpoint, the prognosis for children with Down's syndrome and congenital heart disease is good.     

Changes in ventricular size and plasma renin activity after cardiac surgery in children.

Plasma renin activity and one-dimensional echocardiographic measurements of the left atrium and left ventricle as well as function indices were studied repeatedly in 20 children with various cardiopathies (ages: 9 months to 15 years) before and after corrective surgery. Nine children had tetralogy of Fallot, four had pulmonary stenosis, four had rheumatic heart disease, two had ventricular septal defect, and one had atrial septal defect. Plasma renin activity was normal preoperatively, but increased significantly immediately after surgery, was still significantly higher on the 12th postoperative day and returned to normal six to eight weeks after surgery. Patients with tetralogy of Fallot and pulmonary stenosis had higher plasma renin activity values than the others. There was a positive correlation between plasma renin activity and postoperative percentage change of the left ventricular dimension. In patients with tetralogy of Fallot and pulmonary stenosis, this meant that plasma renin activity became normal when the preoperatively small left ventricle reached its normal dimension. This adjustment occurred slowly over a period of two months. In rheumatic heart disease and left-to-right shunt lesions, plasma renin activities became normal when the preoperatively dilated left ventricle decreased in size towards normal values; the plasma renin activities of these patients had reached normal levels by the fifth postoperative day. The renin secretion is modulated by various factors: of these, ventricular size and pulmonary venous return seem to be of importance.     

Ventricular performance in adults after operation for congenital heart disease

Symptomatic ventricular dysfunction in adults who have had reparative operations for the more common congenital heart defects is uncommon. However, both invasive and noninvasive laboratory assessments of ventricular function have revealed abnormalities in some subsets of patients after repair of atrial septal defect, ventricular septal defect, aortic or pulmonary stenosis, tetralogy of Fallot, transposition of the great arteries and tricuspid atresia. Possible causative factors of late ventricular dysfunction after repair include the duration and severity of volume or pressure overload; the duration and severity of cyanosis; intermittent episodes of imbalance between myocardial oxygen supply and demand; residuae, sequelae and complications of treatment; and acquired disease. Further long-term follow-up studies are needed to assess the effect of current methods of therapy as well as timing of operative intervention on ventricular function in adults.     

Cardiac arrest in patient with significant pulmonary regurgitation after surgical valvulotomy at 10 years of age for isolated pulmonary stenosis

The number of adult patients with a congenital heart defect has increased. They are 2–3 times more numerous than children suffering from congenital heart defects, therefore, it is important to be aware of the most frequent congenital heart defects in adulthood – atrial septal defect, ventricular septal defect, aortic coarctation, tetralogy of Fallot and pulmonary stenosis. These patients either underwent one or more operations in childhood, or were not operated at all (defect was not significant or inoperable), or the heart defect was not diagnosed (mostly atrial septal defect). Some of the patients for various periods of time stop attending regular follow-ups and being asymptomatic (even in cases of hemodynamically significant defects), they do not seek medical attention. We present the case of a 46-year-old man with gradually progressing pulmonary regurgitation after surgical valvulotomy at 10 years of age. Despite regular follow-ups by the cardiologist, the patient was never referred to a specialized centre and cardiac arrest caused by ventricular fibrillation occurred after physical exercise.     

Congenital heart disease in Down's syndrome patients: a decade of surgical experience

Patients with Down's syndrome represent a significant subset of patients with congenital heart disease. Fifty-five patients with Down's syndrome have undergone surgical treatment for congenital heart disease at our institution in the past decade. Twenty-six had atrioventricular canal, 11 had ventricular septal defect, 7 had secundum atrial septal defect, 7 had tetralogy of Fallot, 3 had primum atrial septal defect and 1 patient had double outlet right ventricle. The thirty day mortality following operative intervention was 16.4%. Mortality was highest for tetralogy of Fallot followed by atrioventricular canal and ventricular septal defect. Long term mortality for all lesions was 27.3% over our follow-up period which averaged 33 months. Thirty day mortality compared similarly to previous reports of surgically treated Down's syndrome patients. When compared to our patients without Down's syndrome, the Down's population did not exhibit an increased risk for surgical treatment of congenital heart disease.     

Congenital diverticulum of the right ventricle associated with coarctation of aorta, atrial and ventricular septal defect and ductus.

Congenital right ventricular muscular diverticula are extremely rare and are usually associated with other congenital cardiac anomalies, (in half of the cases tetralogy of Fallot). They functionally behave like an accessory ventricular chamber which contracts synchronously with the normal ventricles.Less than 30 patients with a right ventricular diverticulum have been reported in literature. An apical right ventricular diverticulum occurs in patients with thoraco-abdominal midline defects or abnormalities of the cardiac position([1]). However, an antero-superior diverticulum is usually associated with other congenital cardiac defects, such as a ventricular septal defect, tetralogy of Fallot, double outlet right ventricle and pulmonary stenosis([2--9]).We report an 11-year-old boy with an antero-superior diverticulum of the right ventricle associated with a coarctation of aorta, ductus arteriosus, and atrial and ventricular septum defects. To the best of our knowledge, such an association has not been reported before.     

Levels of brain natriuretic peptide in children with right ventricular overload due to congenital cardiac disease

OBJECTIVE: To evaluate the role of the concentration of brain natriuretic peptide in the plasma, and its correlation with haemodynamic right ventricular parameters, in children with overload of the right ventricle due to congenital cardiac disease. METHODS: We studied 31 children, with a mean age of 4.8 years, with volume or pressure overload of the right ventricle caused by congenital cardiac disease. Of the patients, 19 had undergone surgical biventricular correction of tetralogy of Fallot, 11 with pulmonary stenosis and 8 with pulmonary atresia, and 12 patients were studied prior to operations, 7 with atrial septal defects and 5 with anomalous pulmonary venous connections. We measured brain natriuretic peptide using Triage(R), from Biosite, United States of America. We determined end-diastolic pressures of the right ventricle, and the peak ratio of right to left ventricular pressures, by cardiac catheterization and correlated them with concentrations of brain natriuretic peptide in the plasma. RESULTS: The mean concentrations of brain natriuretic peptide were 87.7, with a range from 5 to 316, picograms per millilitre. Mean end-diastolic pressure in the right ventricle was 5.6, with a range from 2 to 10, millimetres of mercury, and the mean ratio of right to left ventricular pressure was 0.56, with a range from 0.24 to 1.03. There was a positive correlation between the concentrations of brain natriuretic peptide and the ratio of right to left ventricular pressure (r equal to 0.7844, p less than 0.0001) in all patients. These positive correlations remained when the children with tetralogy of Fallot, and those with atrial septal defects or anomalous pulmonary venous connection, were analysed as separate groups. We also found a weak correlation was shown between end-diastolic right ventricular pressure and concentrations of brain natriuretic peptide in the plasma (r equal to 0.5947, p equal to 0.0004). CONCLUSION: There is a significant correlation between right ventricular haemodynamic parameters and concentrations of brain natriuretic peptide in the plasma of children with right ventricular overload due to different types of congenital cardiac disease. The monitoring of brain natriuretic peptide may provide a non-invasive and safe quantitative follow up of the right ventricular pressure and volume overload in these patients.