Bloodless surgery is a comprehensive and systematic perioperative treatment approach in order to avoid allogeneic transfusion for surgery，improve patient prognosis，and relieve blood shortage. Bloodless heart surgery indicates some perioperative strategies to avoid allogeneic transfusion and improve clinical outcomes，which involves participation of cardiac surgeons and other professionals during cardiac surgery. For years，many cardiac surgeons have utilized several blood management and conservation techniques during open heart surgery to avoid allogeneic transfusion. Research results from major medical centers indicate that bloodless heart surgery can shorten postoperative recovery period and improve patientprognosis. In this review，we describe basic theory and systematic methods of bloodless surgery，and summarize applicationprogress of bloodless heart surgery and current status in China.
Surgical treatment of complete transposition of great arteries with ventricular septal defect and pulmonary stenosis (TGA/VSD,PS) consists of Rastelli procedure, Lecompte procedure, Nikaidoh procedure, Yamagishi procedure and Ross-Konno switch procedure. Rastelli procedure and Lecompte procedure cause less myocardial lesion but more late complications. Nikaidoh procedure and Yamagishi procedure achieve better anatomical repair but involve more myocardial lesion. Ross-Konno switch procedure has a narrow surgical indication. So for patients with TGA/VSD,PS, different surgical methods should be used according to surgical indications and individual conditions. In this paper, the advantages and disadvantages, indication, contraindication, outcome and prospect of them are reviewed.
Corresponding author: XU Zhi-wei, E-mail: zwxumd@online.sh.cn Abstract: Objective To compare the two different ways of right ventricle pulmonary artery (RV-PA) reconstruction at repair of persistent truncus arteriosus(PTA), the direct RV-PA anastomosis and extra conduit connection, in order to find the better way. Methods From Feb. 2000 to Sept. 2006, 23 patients had undergone the repairs of truncus arteriosus in our hospital, age at operation from 1.5 to 63.3 months. Patients were divided into 2 groups according to the way of RV PA reconstruction. Group Ⅰ : 18 of them, using direct RV-PA anastomosis, group Ⅱ : 5 of them, using valved homograft or Gore-Tex conduit. 3 patients were associated with interrupted aortic arch (IAA). Kaplan-Meier was used to calculate postoperative mortality, survival time and re-operation situation. Paired t-test and group t-test were used to evaluate late pulmonary growth and cardiac function.Results There were 2 early hospital death, there were 17 patients in follow-up for 2.14 ± 1.97y (32.00d-6.95y). No later death during follow-up. Total survival rateo was 91.30%(21/23), 95% CI of survival time was 5.55-7.15y. Survival ratio of group Ⅰ was 94.40%, and that of group Ⅱ was 80%. One patient had undergone re operation for right ventricular outflow tract obstruction (RVOTO). The difference between the diameter of postoperative RV-PA anastomosis was statistically significant. The early diameter of group Ⅰ was 1.01 ± 0.26cm, later was 1.32 ± 0.45cm(P=0.019). The velocity of flow at the position of anastomosis and the peristome of right pulmonary artery (RPA)/left pulmonary artery (LPA) was acceptable. Compared the postoperative cardiac function, late left ventricle ejection fraction (LVEF) really improved with a significant difference ［ group Ⅰ , early was 62.82%, late was 69.87%(P=0.026); group Ⅱ , early was 58.17%, late was 64.00%(P=0.029) ］ . No re-operation for truncal valve regurgitation was needed. Conclusions The postoperative survival and follow-up results are satisfactory. A direct anastomosis of RV-PA continuity has the potential for right ventricle outflow tract (RVOT) growth and associated with low rate of pulmonary artery and bifurcation obstruction. The heart function is really improved during follow-up. IAA and truncal valve regurgitation are two major risk factors of associated with hospital death.
Abstract: The complete transposition of the great arteries (TGA) is one of the commonest congenital cardiac anomalies in cyanosis. In untreated patients, death occurs early in infancy. Nowadays arterial switch operation (ASO) has been widely proposed to treat TGA without pulmonary valve stenosis. Meanwhile, surgical risks and mortality will be increased if TGA is accompanied by coronary arterial anomalies. So proper surgical management of abnormal coronary artery has a significant influence on the outcome of ASO. The classification, operation methods and surgical results were reviewed in this article.
Abstract:Objective To summarize the experiences of single stage repair of interrupted aortic arch （IAA） associated with cardiac anomalies. Methods From Jan. 2000 to Dec. 2005, 48 patients admited in hospital and 35 patients were operated, the mean age at operation was 1.1 years. The associated anomalies included 23 cases of ventricular septal defect, 2 cases of transposition of great arteries, 3 cases of aortopulmonary window with aortic origin of right pulmonary artery, 2 cases of truncus arteriosus, 2 cases of double outlet right ventricle, 2 cases of stenotic fifth arch and 1 case of aberrant origin of right subclavian artery with mild hypoplastic decending aorta. Among them, 34 patients underwent single stage repair and 1 kid underwent palliative correction. Results There were 4 surgical deaths. The sequelae included one diaphragm paralysis and one 3rd degree of atrioventricular block. Only 5 kids recurred mild stenosis of aortic arch anastomosis and 2 death occurred during 3 months to 4 years of follow-up. Conclusion Though early surgical mortality for primary single stage repair is now relatively low, if appropriate interventions has been accomplished during perioperative period, but outcomes of IAA remain of concern, especially in patients with associated lesions.
Objective To analyze the growth of anastomotic stoma of aortic(AO) and pulmonary artery (PA) after arteries switch operation(ASO) so as to assess the longterm efficacy of ASO . Methods The data of 331 patients who had undergone ASO in Shanghai Children’s Medical Center of Jiaotong University from December 1999 to December 2007 was analysed retrospectively. One hundred eleven patients had complete transposition of great arteries complicated with intact ventricular septum(TGA/IVS), 123 had complete transposition of great arteries complicated with ventricular septal defect(TGA/VSD), 73 had TaussigBing complicated with ventricular septal defect and pulmonary hypertension, and 24 underwent StageSwitch. Of the 331 patients 228 were followedup, and the followup time was 20.4±18.6 months. There were 752 ultrasonic cardiograph reports, 3.3per patient on average. The growth of anastomosis was analysed according to the diameters of AO and PA. Results The AO and PA anastomosis diameters of TGA/IVS patients（before discharge 0.74±0.17 cm and 0.65±0.13 cm, latest followup 1.09±0.31cm and 0.84±0.21 cm）, TGA/VSD patients (before discharge 0.76±0.20 cm and 0.63±0.14 cm, latest followup 1.09±0.24 cm and 0.82±0.22 cm) and TaussigBing patients（before discharge 0.84±0.25 cm and 0.74±0.20 cm, latest followup 1.05±0.30 cm and 0.85±0.24 cm） growed significantly（Plt;0.05）. The AO anastomotic stoma diameters of patients who had underwent StageSwtich (before discharge 0.93±0.19 cm, latest followup 1.19±0.29 cm) growed significantly（Plt;0.05）. The PA anastomotic stoma diameter growed（before discharge 0.90±0.27 cm, latest followup 1.00±0.32 cm）, but had no statistical significance (P＞0.05). Till November 2008, Six patients needed reoperation because of the right or left ventricle outflow tract obstruction. After reoperation, 3 had no residual obstruction, 3 had residual obstruction. Conclusion After the section and suture of ASO, aortic and pulmonary artery can grow with age, but sometimes stenosis happens to some patients. During the followingup, some patients need reoperation.
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.
Abstract： Objective To optimize surgical treatment for children with patent ductus arteriosus （PDA） and mitral regurgitation （MR） and evaluate its midterm to longterm outcome in terms of MR. Methods Between Jan. 2008 and Jan. 2011， 25 children with PDA and MR underwent surgical treatment in Shanghai Children’s Medical Center. There were 14 male patients and 11 female patients with average age of 26.36±40.75 （1.72-142.83）months and average weight of 8.98±6.85 （3.80-36.00） kg. The average diameter of PDA was 7.84±3.10 （3-15）mm. There were 22 children with duct-type PDA and 3 children with window-type PDA. There were 5 children with severe MR， 18 children with moderate MR， and 2 children with mild MR. Except one child with mitral stenosis who underwent PDA ligation plus mitral valvuloplasty supported with cardiopulmonary bypass， all other 24 children only underwent PDA ligation through left posterolateral thoracotomy without any management for the mitral valve. Results There was no in-hospital death. The average ventilation time in ICU was 6.70±4.39 （3-24） hours. Except one child was reintubated because of asthma， all other children recovered uneventfully without any postoperative complication. All the 25 children were followed up for 329.23±288.39 （29-967） days. During follow-up， 23 children （92.00%） had their MR level ameliorated in different degree. Preoperative severe MR in 5 children changed into moderate MR in 2 children and mild MR in 3 children. Preoperative moderate MR in 16 children changed into none MR in 5 children, trivial MR in 5 children and mild MR in 6 children. Preoperative mild MR in 2 children changed into none MR in 1 child and trivial MR in another child. Two children with preoperative moderate MR had no improvement during follow-up. Conclusion For infants and children with PDA and MR， conservative treatment strategy should be carried out. Simple PDA ligation can provide satisfactory clinical outcome， which may also avoid negative complications including myocardial injury caused by cardiopulmonary bypass.