A 63-Year-Old Male with D-Transposition of the Great Arteries Who Had an Early Form of the Arterial Switch Operation

We describe a 63-year-old male who appears to have undergone an early form of the arterial switch operation for D-transposition of the great arteries performed in the mid-1960s.We review the clinical and imaging data that support our conclusion.He had a diagnostic cardiac catheterization which demonstrated severe pulmonary hypertension responsive to epoprostenol and oxygen.Our case may represent one example of the experimental surgical work done prior to Dr.Adibe Jatene’s description of thefirst successful arterial switch performed in 1975.

Anatomic Correlates of Mitral Systolic Anterior Motion in Transposition of the Great Arteries Following Atrial Switch Operation

Introduction:We sought to investigate whether the development of sub-pulmonic systolic anterior motion(SAM)may be inherent to the anatomy of the the mitral valve(MV)or affected by external factors,such as a dilated right ventricle or chest abnormalities in d-looped transposition of the great arteries post atrial switch operation(d-TGA/AtS).Methods:Analysis was performed of clinical and cardiac imaging studies acquired on 19 adult patients with d-TGA/AtS(age 42±6 years old,56%male)between 2015–2019.Echocardiography data included mitral apparatus anatomy,and CT/MRI data included biventricular dimensions,function,and Haller index(HI)for pectus deformity.Results:Patients with leaflet SAM(n=6)compared to patients without SAM(n=13)had higher MV protrusion height(2.3±0.5 vs.1.5±0.4 cm,p≤0.01)and longer anterior MV leaflet length(3.1±0.4 cm vs.2.6±0.3 cm p≤0.05),when compared to those without.CT/MRI showed higher sub-pulmonic left ventricular ejection fraction(LVEF)in the SAM group(71%±8%vs.54%±7%,respectively).RV size and function,significant chest deformity(HI>3.5),presence of a ventricular lead pacemaker,and septal thickness did not play a role in development of SAM.Conclusions:An elongated mitral apparatus is associated with the development of SAM,and the development of left ventricular outflow tract obstruction(LVOTO),in d-TGA/AtS.LV hyperkinesia is associated with SAM.Systemic RV dimensions,septal thickness,and degree of chest deformity did not differ significantly between subjects with SAM and those without.

Noninvasive Assessment of Autonomic Cardiovascular Function in Patients after Arterial Switch Operation for Transposition of the Great Arteries

Background: Children born with transposition of the great arteries (TGA) must undergo corrective surgery for survival, arterial switch being the standard surgical procedure. The sympathetic innervation of the heart may be damaged during the operation. This study was designed to determine whether adults who were born with TGA and who had arterial switch operation (ASO) in infancy exhibit denervation of the heart, measured as heart rate variability (HRV) with electrocardiography (ECG). Methods: Nine patients with transposition of the great arteries (four men and five women;mean age 26 ± 1 years) who underwent the ASO at a mean age of 85 ± 35 days, and nine healthy adults (five men and five women;mean age 26 ± 2) were included in the study. Cardiac autonomic nerve function was determined by the variation in RR intervals during maximal deep breathing, monitored by continuous ECG. The mean values were calculated for each group from six inspirations (I) and expirations (E), and the E:I ratios were calculated. Results: The E:I ratio did not differ between patients with an arterial switch and healthy controls (P?= 0.161). Two patients had signs of denervation of the heart up to 30 years after the arterial switch operation. Conclusions: Reinnervation of the heart?may take place in patients who have undergone the ASO in infancy, and these patients would not necessarily suffer from autonomic dysfunction. The HRV, measured by ECG, has the potential to identify arterially switched patients at risk of developing silent myocardial ischemia.

D-Transposition of the Great Arteries:A New Era in Cardiology

Before the 1950s,D-transposition of the great arteries was associated with nearly 90% mortality within the first year of life.The Mustard and Senning procedures resulted in a signifi cant increase in the lifespan of these patients but with notable long-term complications,including arrhythmias,sinus node dysfunction,chronotropic incompetence,and right ventricular systolic dysfunction.The arterial switch operation(first described by Adib Jatene)initially resulted in nearly universal death.However,the use of coronary buttons for coronary artery translocation has improved operative survival dramatically.It is now considered the treatment of choice in patients amendable to the arterial switch operation.Considered an anatomic repair,resulting in concordant ventriculoarterial connections and a systemic left ventricle,the arterial switch operation reduces the incidence of ventricular dysfunction.However,it is also associated with long-term complications,including aortic root dilatation,aortic valve regurgitation,right ventricular outfl ow tract obstructions,coronary artery stenosis/compression,and branch pulmonary artery stenosis.

Congenitally Corrected Transposition of the Great Arteries: Conduction Anomalies: A Case Report

Introduction: Congenitally corrected transposition of the great arteries (CCTGA) is a rare heart disease that encompasses an atrioventricular and ventriculoarterial discordance and accounts for less than 1 percent of congenital heart diseases. Objective: To present an atypical case of a man with complex congenital heart disease and conduction anomalies. Case Presentation: This is a case of a 34-year-old patient who came to the hospital with 1 week of dyspnea on exertion and episodes of lipothymia. The patient was referred to our hospital after an electrocardiogram from his primary care with evidence of blocked atrial fibrillation. During the initial evaluation blocked atrial fibrillation was confirmed with a rescue ventricular rate of 38 bpm. A magnetic resonance confirmed the presence of the atrioventricular and ventriculoarterial discordance, the aorta had a left anterior position, perimembranous ventricular septal defect with a right to left shunt, biventricular systolic dysfunction, moderate tricuspid, and mitral regurgitation, interventricular septal intramyocardial and biatrial fibrosis, left atrial dilation, and dilation of the pulmonary artery. After pacemaker placement, the patient has an improvement in his clinical symptoms and quality of life. Conclusions: Cardiac arrhythmias are CCTGA’s leading cause of death, mostly ventricular tachycardia, and atrial fibrillation. Right bundle branch block is a previously unreported and potentially very rare presentation of this disease. This, added to the fact that our patient was diagnosed at an advanced age, but without symptoms of heart failure, makes him an atypical case of CCTGA, with new potential treatment options.

D-Transposition of Great Arteries in a Primigravida of 35 Years Old-Case Report and Literature Review

This is a case report with discussion of the maternal-fetal outcome of pregnant women with uncorrected transposition of the great arteries （TGA） associated with pulmonary arterial hypertension and a large ventricular septal defect. This case draws attention to the severity of the pathology and maternal symptoms prior to gestation, and how an adequate clinical management of both obstetrics and cardiology can provide a favorable outcome for mother and fetus.

Comparative analysis of early and middle outcomes of the arterial switch operation in children with complete transposition of the great arteries with ventricular septal defect and severe pulmonary artery hypertension

Background The best age for the arterial switch operation （ASO） in complete transposition of great arteries with ventricular septal defect is usually considered to be within six months. This is because of severe pulmonary arterial hypertension and pulmonary arterial obstructive pathological changes. There are few reports on ASO surgery in children older than three years old. Methods We studied 41 children, including 24 males and 17 females, from January 2010 to December 2011. They were divided into three groups by operation age; 15 patients were 〈1 year old, 13 were 1-3 years old, and 13 were 〉3 years old. Associated cardiac abnormalities included patent ductus arteriosus in six cases, atrial septal defect in five cases, and mitral regurgitation in two cases. All the patients had echocardiography before the operation. Seventeen patients underwent a coronary computed tomography examination and five patients underwent right heart catheterization. All ASO surgeries were performed under inhalation anesthesia and hypothermic cardiopulmonary bypass. Results Three operative deaths occurred. Two were in the 〈1 year old group, who died from severe postoperative low cardiac output. The other was two years old and died of postoperative multiple organ failure. There was no significant difference in postoperative mortality and the recent mid-term survival rate among the three groups. Thirty-eight cases were followed up for an average of 11.2 months, ranging 6-20 months. One seven years old patient died of acute diarrhea and electrolyte disturbance arrhythmia caused by food poisoning. Three patients more than three years old still had residual pulmonary arterial hypertension. Conclusion Children older than three years old can still undergo the ASO procedure, but residual pulmonary hypertension is present.

Six-Year Outcome after Valve Replacement and Resynchronization Therapy in TGA Patient

Patients with complete transposition of the great arteries(TGA)treated by the Senning procedure have a higher risk of developing heart failure due to:a)additional work load of the systemic(morphologic right)ventricle(sRV),b)arrhythmias,mainly caused by surgical implications at the atria as well as c)worsening of systemic tricuspid regurgitation.We present a unique case of a female patient who developed all these complications,who was successfully treated and was able to carry out a twin pregnancy.This breakthrough approach was based on:1.detecting reversibility potential of myocardial systolic dysfunction in a severe valvular lesion combined with continuous systemic afterload settings and permanent tachyarrhythmia,and 2.prevention of subsequently iatrogenic worsening of systemic ventricular function due to permanent pacing.Surgical replacement of systemic tricuspid valve(sTV)and cardiac resynchronization device(CRT)implantation after nodal ablation resulted in recovering of the systolic function and a positive remodeling of the sRV.The reversal of a further decline in systolic function was achieved by permanent arrhythmia control,synchronous pacing with epicardial leads of CRT,sTV replacement as well as echocardiographic monitoring during pregnancy to determine the right time for delivery.Two years after delivery,the patient remains in NYHA Class I.

冠心病患者非心脏手术围术期心血管不良事件的危险因素分析

目的分析冠心病患者非心脏手术围术期主要心血管不良事件(MACE)的危险因素。方法回顾性分析2014-01-01/2019-12-31期间在广西医科大学第一附属医院接受非心脏手术冠心病患者619例,根据是否发生MACE将患者分为事件组(n=36)和非事件组(n=583),采用多因素Logistic回归分析冠心病患者围术期MACE的独立危险因素。观察终点为麻醉开始至患者出院期间发生的MACE,包括恶性心律失常、心肌梗死、心力衰竭及心源性死亡,记录及比较2组患者临床资料。结果冠心病患者非心脏手术围术期MACE发生率为5.8%(36/619)。多因素Logistic回归分析显示,ASAⅣ级(OR=18.515)、脑血管病史(OR=3.599)、不稳定性心绞痛史(OR=5.152)、心肌梗死史(OR=5.421)、急诊手术(OR=4.551)、腹部手术(胃肠、肝胆手术)(OR=10.384)、术中出血量500~1500 mL(OR=21.055)及术中出血量≥1500 mL(OR=83.885)是冠心病患者非心脏手术围术期MACE的危险因素(P<0.05),差异有统计学意义。结论ASAⅣ级、脑血管病史、不稳定性心绞痛史、心肌梗死史、急诊手术、腹部手术(胃肠、肝胆手术)、术中出血量是冠心病患者非心脏手术围术期MACE的危险因素。

A clinical study on the effects of ICU cardiac rehabilitation nursing care on patients with totally thoracoscopic cardiac operation

Background The video-assisted thoracoscopic surgical techniques are widely used in the treatment of patients with congenital heart diseases with good outcomes. However, the feasibility and significance of nurse based early cardiac rehabilitation in cardiac intensive care unit （ICU） for patients with totally thoracoscopic cardi- ac operation has been seldom studied. Methods Thirty-six patients with totally thoracoscopic cardiac operation under the condition of the cardiac ICU in Guangdong General Hospital were random allocated to the intervention group and the control group between January 2012 to December 2014. The control group received standard nursing care, and the intervention group received early cardiac rehabilitation nursingcare in addition to standard care. The outcome measures included the oxygen saturation （SPO2%）, vital capacity, forced expiratory volume in 1 second （FEV1）, and pain in the thoracic wound （visual analogue scale, VAS）, which were measured at the baseline and within 2-day after 4-week nursingcare. For safety reason, we also monitored the rate of perceived exertion （RPE）, heart rate, systemic blood pressure. Results There were non-significant differences between the groups in age, sex, total number of comorbid conditions, total number of medications, surgical time, and anesthetic time （P〉0.05）. Following 4 weeks treatment, the cardiopulmonary functions and VAS scorewere improved （P〈0.05） in all groups. In addition, the improvements were more in the early cardiac rehabilitation nurse care group than in the control group （P〈0.05）. Conclusion The early cardiac rehabilitation nursing care in cardiac ICU is safe, feasible and beneficial for patients with totally thoracoscopic cardiac operation.

剖腹产术合并大血管手术体外循环管理

目的:总结剖腹产术合并大血管手术体外循环管理体会。方法:1例主动脉夹层、高血压3级(极高危组)、宫内孕35 w、左肾切除术后及室上速射频消融术后的患者经药物治疗无效,妇科先行剖腹产、子宫切除术,妇科术毕,在体外循环下,行升主动脉替换及Sun's术。结果:患者术后12 h清醒,39h拔出气管插管,手术后母婴平安,孕妇顺利恢复。结论:针对大血管手术的方式选择体外循环方法,根据孕妇的生理特点,合理制定体外循环计划,以减少患者的并发症,提高手术的成功率。

大动脉调转术纠治完全性大动脉转位的外科治疗体会

目的研究和探讨完全性大动脉转位行大动脉调转术外科手术治疗和临床结果分析。方法自2003年8月至2015年12月,我院共完成完全性大动脉错位行大动脉调转术(Switch术)31例,一期Switch术29例,二期Switch术2例,室间隔完整型大血管错位(D-TGA/IVS)18例,合并室间隔缺损(D-TGA/VSD)13例,男21例,女10例,年龄5h-6M(25±10.3d),体重2.4-6(3.50±1.22)kg。结果全组31例,手术死亡2例均为冠脉畸形,术后早期监护室死亡2例,其余均康复出院,随诊1个月-5年远期无死亡,心脏超声复查恢复良好,肺动脉轻度残余梗阻1例。结论完全性大动脉转位可以通过一期或两期大动脉调转术进行外科手术纠治,在新生儿期及早发现,早期手术,熟练手术精细操作,冠脉动脉移植保证心肌血运,是手术成功的关键。

快速二期动脉调转术应用的体会

目的：报告采用快速二期动脉凋转术（ASO），治疗完全性大动脉转位（TGA）合并完整室间隔畸形的初步体会。方法：2006年1月至2007年1月，采用快速两期ASO治疗4例室间隔完整型TGA患儿。年龄1．2个月～20个月；体重4．0～9.5k。一期手术主要采用肺动脉环缩及Blalock-Taussig分流术进行左心室功能训练。至二期ASO前，左心室心肌质量、舒张末径和容积、室间隔和左心室后壁厚度分别较左心室训练前增长了102％～120％、30．3％～37．5％、79．1％～143，6％、5．5％～26．7％和20％～50％。室间隔位置由偏向左心室侧转为偏向右心室侧或居中。二期手术间隔5～19d。结果：术后早期均无心肌缺血及明显低心排出量综合征表现。存活3例，另1例在二期手术体外循环过程中及术后早期无尿，术后28h死于肾功能衰竭。结论：对于年龄错过新生儿期室间隔完整型TGA患儿，在根治手术前采用肺动脉环缩先对左心室进行功能训练，为一种可选择的、有效的方法。

风湿性心脏病合并冠心病的同期外科治疗

目的探讨风湿性心脏病合并冠心病的同期外科治疗,提高手术效果。方法回顾性分析9例患者同期施行冠状动脉旁路移植术和心脏瓣膜手术的临床资料及远期随访资料,其中二尖瓣置换6例,二尖瓣成形2例,主动脉置换1例。合并冠状动脉单支病变中7例用左乳内动脉做血管桥,二支病变中1例用左乳内动脉加大隐静脉做血管桥,1例用左乳内动脉加左桡动脉做血管桥。结果术后平均呼吸机辅助时间19h,平均重症监护室监护时间2.6天,出院前行超声检查心功能,射血分数上升0%～20%。发生呼吸功能不全3例,严重心律失常3例,出血再次开胸1例,经治疗均好转。心绞痛不同程度消失,无围手术期死亡,远期随访心功能明显改善。结论积极、正确的围手术期处理,改善心功能,尽量缩短主动脉阻断时间,术中心肌保护良好,是提高瓣膜病合并冠心病患者手术成功率、降低死亡率、减少并发症的关键。

选择性脑灌注在新生儿及婴幼儿大血管手术中的应用

目的探讨新生儿及婴幼儿大血管手术深低温停循环中,结合应用选择性脑灌注(selective cerebral perfusion,SCP)对脑的保护安全性和可行性。方法 2009年4月至2011年5月行一期主动脉弓部重建的患儿18例(新生儿6例,婴幼儿12例),主动脉弓离断8例及主动脉弓缩窄10例,均合并室间隔缺损,其中合并动脉导管未闭12例,合并卵圆孔未闭14例。采用复方电解质注射溶液、红细胞、血浆、20%人血白蛋白、甲基强的松龙等预充,血液稀释后红细胞压积0.25～0.30。结果所有患儿心脏均自动复跳,自动复跳率为100%,无恶性心律失常;体外循环(cardiopulmonary bypass,CPB)时间103～201 min[(141.16±28.15)min];主动脉阻断时间(67.94±10.61)min;SCP时间(38.11±10.81)min;SCP灌注流量(20.31±9.21)ml/(kg.min);清醒时间(4.19±1.68)h;机械通气时间(63.22±27.66)h;ICU滞留时间(5.8±2.17)d;住院时间(20.33±6.06)d;CPB中尿量(86.94±59.43)ml;超滤液总量(1053.88±431.04)ml;改良超滤出液量(143.05±23.83)ml。所有患儿术后无神经系统并发症,均痊愈出院。结论 SCP在新生儿及婴幼儿大血管手术中是可行且安全的脑保护方法。

78例动脉调转手术在复杂先天性心脏病治疗中的临床应用

目的:回顾总结近年来动脉调转术(ASO)治疗心室大动脉连接异常复杂先天性心脏病(先心病)的手术疗效,探讨手术适应证。方法:2000年1月至2004年12月,对78例患儿行动脉调转术,其中室间隔完整型[或含小的室间隔缺损(VSD)]大动脉转位(TGA),为室间隔完整型组30例;<6个月的VSD型TGA和右心室双出口合并肺动脉瓣下VSD(简称TaussigBing畸形),为<6个月VSD型组20例;>6个月合并中～重度肺动脉高压的VSD型TGA和TaussigBing畸形,为>6个月VSD型组24例;矫正型TGA为矫正型TGA组4例。平均年龄(8.55±14.84)个月(2天～11岁)。合并主要畸形:左心室流出道狭窄7例,肺动脉瓣轻～中度狭窄7例,肺动脉瓣重度狭窄1例,主动脉弓中断1例,肺动脉瓣下隔膜1例,主动脉瓣下隔膜1例,镜面右位心1例。在全麻、低温(18～22℃)、低流量[50ml/(kg·min)]体外循环下完成动脉调转术,合并畸形者同期矫治。结果:全组病死率为14.1%(11/78)。其中室间隔完整型组、<6个月VSD型组、>6个月VSD型组和矫正型TGA组病死率分别是13.3%(4/30)、15.0%(3/20)、12.5%(3/24)、25.0%(1/4)。67例患者痊愈出院。平均随诊13.5±7.9(0.5～56)个月,心功能明显改善,紫绀消失,活动量增加,发育正常,无死亡和远期并发症发生。结论:动脉调转术是解剖矫治TGA、TaussigBing畸形及矫正型TGA的首选术式。对年龄较大(>6个月)、合并中～重度肺动脉高压、合并复杂畸形同期矫治以及一期姑息术后的二期动脉调转术患儿,手术疗效及中期随访结果满意。

冠状动脉旁路移植术同期行心脏瓣膜置换手术59例临床分析

目的 研究冠状动脉旁路移植同时行心脏瓣膜置换手术治疗非缺血性心脏瓣膜疾病合并冠心病的疗效.方法 59例冠状动脉旁路移植同时行瓣膜置换手术,包括二尖瓣瓣膜病变40例及主动脉瓣瓣膜病变11例,联合瓣膜病变8例,共搭桥132支.根据患者年龄及病变血管情况选用乳内动脉或大隐静脉作为血管桥.结果 本组1例术后1d死亡,死亡原因是严重的低心排综合征,搭桥4根.其他病例术后随访2个月至7年,均没有明显心绞痛复发并且心功能得到改善.结论 非缺血性心脏瓣膜疾病合并冠心病患者一般无典型心绞痛病史,有冠心病高危因素的患者术前应该常规行冠状动脉造影检查明确是否合并冠心病.采取术前改善心功能状态,缩短手术及心肌缺血时间等措施,同时行冠状动脉旁路移植手术及心脏瓣膜手术是有效可行的治疗手段.

70岁以上心脏病患者手术治疗体会

目的 总结 70岁以上心脏病患者的手术治疗体会。方法 自 1995年 5月至 2 0 0 0年 7月进行 70岁以上高龄患者心脏手术 2 3例 ,单纯冠状动脉搭桥术 13例 ,单纯瓣膜手术 5例 ,瓣膜手术同时冠状动脉搭桥术 3例 ,心包剥脱同期冠状动脉搭桥术 1例 ,左房粘液瘤摘除术 1例。结果 术后出现并发症 5例 (2 1.7% ) ,死亡 1例 (4.3 % ) ,无围术期心肌梗塞、高血压危象和酮症酸中毒等。存活 2 2例随访 1个月～ 5年 ,心功能和生活质量明显改善。结论 高龄心脏病应及时就诊 ,一旦有手术适应证应尽早外科治疗 ,临床效果满意 ,积极的围术期管理是手术成功的关键。

儿童先天性矫正大动脉转位解剖矫治术早期疗效初探

目的:探讨儿童先天性矫正大动脉转位(cTGA)解剖矫治术早期疗效。方法:2002年4月至2007年10月我科行双调转手术治疗cTGA合并心内畸形患儿14例,其中男性10例,女性4例;年龄6个月至16岁,平均9.14岁。全组均在全麻深低温低流量体外循环下行心内直视解剖矫治手术。手术方式包括改良Senning+Rastelli13例,Mustard+Rastelli+双向Glenn术。结果:术后早期死亡2例,死亡原因为低心排出综合征(低心排)和左心功能衰竭。早期主要并发症有低心排、房室分离各1例,胸腔积液和低蛋白血症2例。随访2～24个月,恢复良好,复查多普勒超声心动图、心电图和X线胸片显示,窦性心律11例,结性心律1例,心功能均为Ⅰ级。结论:SLL型病例采用改良Senning心房内调转手术效果优于Senning和Mustard手术。双调转手术可以达到解剖矫治cTGA合并心内畸形,早期手术病死率低,中、远期心功能效果良好。

应用一期大动脉调转术治疗完全性大血管错位

目的探讨一期大动脉调转术(Switch术)在完全性大血管错位(D—TGA)中的应用。方法 2004年4月至2009年3月应用一期Switch术治疗完全性大血管错位10例。其中室间隔完整型大血管错位(D-TGA/IVS)5例,大血管错位伴室间隔缺损(D-TGA/VSD)5例;手术平均年龄(39±21.8)d,体重(3.65±1.24)kg。结果手术死亡2例,其余随访3个月-4年,心脏彩超提示心脏功能状况良好,肺动脉轻度残余梗阻1例。结论一期Switch术在完全性大血管错位中的应用可以取得良好的手术效果,及早手术和冠状动脉移植的通畅,是手术成功的关键。