Right Axillary Thoracotomy Should Be the Standard of Care for Repair of Non-Complex Congenital Heart Defects in Infants and Children

Minimally invasive approaches for cardiac surgery in children have been lagging in comparison to the adult world.A wide range of the most common congenital heart defects in infants and children can be repaired suc-cessfully through a variety of non-sternotomy incisions.This has been shown to be associated with superior cos-metic results,shorter hospital stays,and rapid return to full activity compared to sternotomy.These approaches have been around for decades,but they have not been widely adopted for a variety of reasons.Right axillary thor-acotomy is one of these approaches that we believe should be the new standard for the repair of a wide variety of heart defects in children and will be the focus of our current review.

Arrhythmic Risk in Paediatric Patients Undergoing Surgical Repair for Pulmonary Atresia with Intact Ventricular Septum

Introduction:While previous studies only focused on the arrhythmic risk associated with specific correction strategies,this study evaluates this risk in a large cohort of paediatric patients with all phenotypes of PA-IVS after surgical repair.Methods:In this single centre observational cohort study,we retrospectively evaluated 165 patients with a diagnosis of PA-IVS and we excluded those with an exclusively percutaneous treatment,patients lost or with insufficient follow-up and those affected by other arrhythmic syndromes.Surgical history and clinical outcomes were reviewed.Results:86 patients were included in the study(54 male[62.8%],mean age 16.4±6.1 years),with median follow-up from definitive repair of 12.8 years(6.4–18.9 years).They underwent three different final repairs:23 patients(26.7%)univentricular palliation,43(50%)biventricular correction,and 20(23.3%)one and a half ventricle correction.Thirteen patients(15%)developed arrhythmia:6 patients(all the subgroups)sinus node disfunction(SND);2(biventricular repair)premature ventricular complexes;2(one and a half ventricle repair)non-sustained ventricular tachycardia;1(biventricular repair)intra-atrial re-entrant tachycardia;1(one and a half ventricle repair)supraventricular tachyarrhythmia;1(biventricular repair)atrial fibrillation.Three patients with SND needed a pacemaker implantation.Only Fontan circulation showed an association with SND,while the other two groups heterogeneous types of arrhythmias.Conclusions:The low arrhythmic risk is related to surgical repair,it does not appear to be associated with native cardiomyopathy,and it appears to increase with length of follow up.Continuous follow-up in specialized centres is necessary to make an early diagnosis and to manage the potential haemodynamic impact at medium-long term.

Hybrid Repair of Two Consecutive Acute Ventricular Septal Ruptures after Evolving Myocardial Infarction: Case Report

Background: Acute Ventricular septal rupture is one of dreadful complications of acute evolving myocardial infarction. Despite urgent management is lifesaving, it is still challenging and has a high risk of mortality particularly if recurrent or residual defects occurred. Evolving of skillfulness in transcatheter intervention of heart diseases paved the way for successful hybrid management of challenging cardiac cases specially for residual complicated cases post cardiac surgery. Case Presentation: We described here a successful hybrid two stage technique (surgical then transcatheter approach) to close two consecutive acute ventricular septal ruptures in 75 years old female presented with cardiogenic shock post evolving myocardial infarction. Conclusion: Hybrid repair by surgical and transcatheter interventions may be a good therapeutic modality for acute septal ruptures specially for residual or new defects after initial closure.

Mitral Valve Repair for Mitral Valve Regurgitation with Papillary Muscle Displacement and Posterior Leaflet Prolapse

A case of abnormal chordae of the mitral valve (MV) associated with systolic anterior motion (SAM) is not commonly encountered in clinical practice. Here we report MV repair via the edge-to-edge technique in a 56-year-old male with MV regurgitation associated with papillary muscle displacement and posterior leaflet prolapse. Echocardiography revealed obstruction of the left ventricular outflow tract caused by SAM because of papillary muscle displacement and mitral regurgitation associated with posterior leaflet prolapse due to chordae rupture. MV repair was successfully performed by reconstruction with an Alfieri stitch. The outcome of this case demonstrated that this surgical technique is preferable for MV abnormalities with no complex malformations.

Impact of cardiac magnet resonance imaging on management of ventricular septal rupture after acute myocardial infarction

A 74-year-old man was admitted to the cardiac catheterization laboratory with acute myocardial infarction. After successful angioplasty and stent implantation into the right coronary artery, he developed cardiogenic shock the following day. Echocardiography showed ventricular septal rupture. Cardiac magnet resonance imaging (MRI) was performed on the critically ill patient and provided detailed information on size and localization of the ruptured septum by the use of fast MRI sequences. Moreover, the MRI revealed that the ventricular septal rupture was within the myocardial infarction area, which was substantially larger than the rupture. As the patient's condition worsened, he was intubated and had intra-aortic balloon pump implanted, and extracorporeal membrane oxygenation was initiated. During the following days, the patient's situation improved, and surgical correction of the ventricular septal defect could successfully be performed. To the best of our knowledge, this case report is the first description of postinfarction ventricular septal rupture by the use of cardiac MRI in an intensive care patient with cardiogenic shock and subsequent successful surgical repair.

Management of Left Ventricular Aneurysm: A Study from Iraq

Background: The most appropriate surgical approach for post-myocardial infarction left ventricular aneurysm (LVA) is controversial. This study aims to display the results of surgical treatment of LVA in a major Iraqi cardiac surgical center. Methods: The surgical management of LVAs over the period 2001 to 2011 was retrospectively reviewed. The presenting signs and symptoms, results of investigations, operative findings, and outcomes of patients were determined. Results: Twenty-seven true LVAs associated with 4 ventricular septal defects (VSDs) were treated surgically. During the same period, 1136 coronary artery bypass graft (CABG) operations were done, thus LVA represented 2.4%. Males constituted the majority (74.1%). The mean age was 54.6 years old. The typical ECG changes were seen in 42.1%. Apical and antero-apical locations predominated. The majority of patients (84.2%) had subnormal values of ejection fraction (EF). Most patients had multi-vessel coronary artery disease (CAD). The most frequent was the left anterior descending artery (LAD). All patients had CABG except 3. Linear repair and Dor technique were used equally. The commonest postoperative complication was bleeding (38.4%). The overall hospital mortality was 18.5%. Conclusion: Concomitant CABG improves early postoperative course and must be added when significant lesions in coronary arteries particularly the LAD are present.

鼻咽癌细胞株CNE1、HONE1、C666-1和CNE2的亚致死性损伤修复速度测定

目的测定CNE1、HONE1、C666-1和CNE2的亚致死性损伤修复速度参数-半修复时间(repair half-time,T1/2)。方法设0s、15s、30s、1h、2h、4h及6h共7个间隔时间,将8Gy照射剂量分为平分为两个4Gy间断照射4株细胞。采用集落形成法得到4株细胞在不同间隔时间两个4Gy照射后的存活分数。拟合细胞存活分数随间隔时间延长的变化曲线,并测算出T1/2。结果CNE1、HONE1、C666-1和CNE2的T1/2分别为18、22、29和27s。结论鼻咽癌细胞的亚致死性损伤修复速度较快。提示调强放疗中被延长的分次照射时间(15～45s)可能导致鼻咽癌细胞的辐射死灭效应降低。

中国大陆室间隔缺损经导管堵闭与外科手术治疗的Meta分析

目的室间隔缺损(VSD)是先天性心脏病中最常见的类型,目前其根治方法有经导管堵闭和外科手术修补。采用Meta分析方法评估中国大陆经导管堵闭和外科手术修补VSD对照研究的疗效和安全性,为临床优化治疗提供一定的参考依据。方法通过检索中、外文数据库,全面收集中国大陆经导管堵闭与外科手术治疗VSD的文献。制定文献的纳入及排除标准,由2名研究者分别独立筛选文献,符合纳入标准的文献按Shekelle等建议的标准进行文献质量评估。对患者的年龄、体重、VSD大小和住院天数等进行分析比较;对手术成功率、残余分流发生率和并发症发生率等应用RevMan4.28软件进行Meta分析。结果7篇文献纳入分析,均为单中心的非随机对照研究(Ⅱa级)。经导管堵闭组和外科手术组年龄差异无统计学意义,经导管堵闭组患者的体重较重,治疗的VSD直径较小。Meta分析结果显示:经导管堵闭组的成功率低于外科手术组(97.6%vs99.2%,P=0.007);两组病死率差异无统计学意义(0vs1.4%,P=0.51);两组残余分流发生率差异无统计学意义(2.5%vs3.2%,P=0.91);经导管堵闭组的并发症发生率低于外科手术组(10.1%vs25.7%,P<0.00001);两组心律失常发生率差异无统计学意义(5.5%vs6.6%,P=0.61);经导管堵闭组的术后感染发生率低于外科手术组(0vs7.6%,P=0.002)。结论经导管堵闭VSD具有创伤小、安全性高和术后恢复快等优点,但治疗有选择性,长期疗效需进一步随访。对具有适应证的VSD患者,可优先考虑经导管堵闭治疗。

右心室Overhaul技术在复杂先心病合并右心室发育不良手术中的运用

目的总结右心室Overhaul技术在治疗伴右心室发育不良的复杂先天性心脏病中的运用经验,探讨术中操作要点,评估其近中期疗效。方法回顾性分析我科2006年1月至2021年4月间采用右心室Overhaul技术治疗的合并有右心室发育不良的22例先天性心脏病患者的临床资料,男14例,女8例,其中室间隔完整的肺动脉闭锁15例,房室间隔缺损伴动脉导管未闭2例,三尖瓣下移畸形伴房间隔缺损3例,三尖瓣发育不良伴动脉导管未闭及房间隔缺损2例。所有患者术前均经超声心动图明确具有右心室发育不良。术中使用右心室Overhaul技术扩大右心室腔,并同期处理部分合并的心脏畸形。结果全组患者均顺利完成右心室Overhaul手术及部分合并畸形的矫治,围术期无死亡病例。术后呼吸极辅助通气时间(16.9±13.5)h,术后住院时间(7.2±2.8)d;术后/术前右心室容积比为(2.3±0.9)倍。随访3个月~15年,2例患者分别随访2年及4年后因右心室腔小、明显发绀,再次行右心室Overhaul手术,14例患者随访右心室发育情况良好,再行根治手术。6例患者仍在随访中。所有患者首次手术后末梢氧饱和度及活动耐力较术前明显提高,患者心功能Ⅰ~Ⅱ级,活动耐量良好。结论右心室Overhaul技术可安全用于部分具有双心室结构,但右心室发育不良无法一期行根治手术的复杂先天性心脏病患者,可有效提高末梢氧饱和度、改善患者活动能力,并为可能的双心室根治手术创造条件。

CABG同期行左室成形术和二尖瓣成形术治疗左室室壁瘤并发二尖瓣关闭不全的效果

目的评价冠状动脉旁路移植术(CABG)同期行左室成形术和二尖瓣成形术治疗左室室壁瘤并发二尖瓣关闭不全的近远期临床效果。方法自2000年1月~2008年12月,我院共32例患者因左室室壁瘤并发缺血性二尖瓣关闭不全同期进行左室成形术+二尖瓣成形术。左室成形术手术方式包括:线性缝合16例(50%);心内膜环缩成形术9例(28%);心室内环状补片成形术7例(22%)。二尖瓣成形术入路包括:左室入路20例(62%),右房-房间隔入路11例(34%),房间沟入路1例(3%)。全部患者均同期行CABG。本研究回顾性分析了上述患者手术中及围手术期的临床资料,并进行了46~175个月随访。结果围手术期死亡1例(3%)。术后1年和5年生存率分别为97%和74%。随访期间,9%(3例)出现二尖瓣中量及以上返流,9%(3例)出现NYHA心功能III^IV级。左室成形方式及二尖瓣成形入路对远期效果无显著影响。结论左室成形术同期行二尖瓣成形术是治疗左室室壁瘤并发二尖瓣关闭不全的有效方法,术后的近远期临床结果令人满意。

Appropriate Heart Rate in a Patient with Repaired Tetralogy of Fallot

Appropriate heart rate in a failing pulmonary ventricle remains unknown, particularly in congenital heart diseasewith unique hemodynamics. A 71-year-old male with repaired tetralogy of Fallot and a pacemaker for a sinusnode dysfunction suffered from heart failure symptoms with preserved left ventricular function. Simply changingthe pacemaker’s lower rate from 60 to 75 bpm, New York Heart Association classification improved from III to II,and hemodynamic parameters drastically improved. We regarded this case as informative. Appropriate heart ratecould be higher in congenital patients with failing right and non-failing left ventricles than in adults with malfunctioningLV.

右心室功能障碍预测原发性二尖瓣反流经导管二尖瓣修复术后疗效的临床价值

目的:探讨右心室功能障碍(right ventricular dysfunction,RVD)预测原发性二尖瓣反流(mitral regurgitation,MR)经导管二尖瓣修复术(transcatheter mitral valve repair,TMVR)后疗效的临床价值。方法:选取2019年3月至2021年5月在我院就诊的60例症状性MR患者作为研究对象,根据CMR中右心室射血分数(right ventricular ejection fraction,RVEF)是否低于45%,分为MR+RVD组(n=25)及单纯MR组(n=35)。探讨RVD对预测MR患者术后死亡和再入院的价值。结果:16例患者(26.7%)显示右心室扩张。随访期间,14例患者全因死亡(23.3%),20例(33.3%)患者因心力衰竭等原因再次入院。根据受试者工作特征曲线,RVEF预测死亡和再入院的最佳截断值分别为34.6%和44.9%。MR患者中左右心室舒收缩期容积指数、左右心室每搏量指数、LVEF与REVF均呈正相关性(r=0.420、0.490、0.447,P<0.05)。RVEF与肺动脉收缩压呈负相关(r=-0.292,P=0.028)。Cox模型结果显示调整左心室参数后,RVD也可预测再入院风险和全因死亡风险(P<0.05)。与单纯MR组患者相比,MR+RVD组患者的再入院时间和全因死亡时间缩短(P<0.05)。结论:即使在有效的TMVR之后,术前RVD也与不良预后相关。同时出现RVD、右心室扩张和肺动脉高压的患者队列显示出更高的全因死亡率。

Surgery for left ventricular aneurysm after myocardial infarction： techniques selection and results assessment

Background The most appropriate surgical approach for patients with post-infarction left ventricular （LV） aneurysm remains undetermined. We compared the efficacy of the linear versus patch repair techniques, and investigated the mid-term changes of LV geometry and cardiac function, for repair of LV aneurysms. Methods We reviewed the records of 194 patients who had surgery for a post-infarction LV aneurysm between 1998 and 2010. Short-term and mid-term outcomes, including complications, cardiac function and mortality, were assessed. LV end-diastolic and systolic dimensions （LVEDD and LVESD）, LV end-diastolic and end-systolic volume indexes （LVEDVI and LVESVI） and LV ejection fraction （LVEF） were measured on pre-operative and follow-up echocardiography. Results Overall in-hospital mortality was 4.12%, and major morbidity showed no significant differences between the two groups. Multivariate analysis identified preoperative left ventricular end diastolic pressure 〉20 mmHg, low cardiac output and aortic clamping time 〉2 hours as risk factors for early mortality. Follow-up revealed that LVEF improved from 37% pre-operation to 45% 12 months post-operation in the patch group （P=0.008）, and from 44% pre-operation to 40% 12 months postoperation in the linear group （P=0.032）. In contrast, the LVEDVI and LVESVI in the linear group were significantly reduced immediately after the operation, and increased again at follow-up. However, in the patch group, the LVEDVI and LVESVI were significantly reduced at follow-up. And there were significant differences in the correct value changes of LVEF and left ventricular remodeling between linear repair and patch groups. Conclusions Persistent reduction of LV dimensions after the patch repair procedure seems to be a procedure-related problem. The choice of the technique should be tailored on an individual basis and surgeon＇s preference. The patch remodeling technique results in a better LVEF improvement, further significant reductions in LV dimensions and volumes than does the linear repair technique. The results suggest that LV patch remodeling is a better surgical choice for patients with post-infarction LV aneurysm.

Assessment of right ventricular strain in children with repaired tetralogy of Fallot using speckle tracking imaging

To the Editor: Tetralogy of Fallot (TOF) was first surgically repaired in 1955. Initial TOF repairs were performed using a trans-annular right ventricular outflow tract patch to relieve the obstruction. However, this procedure resulted in long-standing pulmonary valve regurgitation and increased right ventricular (RV) volume, causing arrhythmias and sudden death.[1] Thus, pulmonary annulus preservation became the most prevalent surgical strategy for TOF repair, possibly causing a mix of pulmonary stenosis and pulmonary valve regurgitation. Currently, clinicians concerned with RV function decrease during the long-term follow-up use of cardiac magnetic resonance imaging (CMR) to predict the appropriate timing of interventions for valve sparing. Although CMR techniques have evolved as the reference standard for assessing RV volumes and function during the last two decades, routinely monitoring the progression of repaired tetralogy of Fallot (rTOF) RV dysfunction remains difficult.

连续压机上一种哈夫链轮加工工艺的研究

通过加工过程中不断对变形机理的分析和控制,确定一种精密能同步、哈夫可互换的特种链轮的工艺方法。采取应力两次释放,数控加工修齿、专用工装和检具等工艺手段,保证设计要求的实现。

儿童室间隔缺损改良修补术的早中期疗效及并发心律失常的预测模型构建

目的分析儿童室间隔缺损采用改良修补术后早、中期疗效。并对术后并发心律失常的因素进行分析,并构建风险预测模型。方法收集徐州市儿童医院2022年10月至2023年10月收治的儿童间隔缺损患儿100例临床资料,患儿均进行改良修补术治疗。观察患儿围术期各指标、术前术后心功能情况。并对患儿术后发生心律失常及未发生者各项参数指标进行分析,采用受试者工作特征曲线(receiver operator characteristic curve,ROC曲线)绘制心律失常的预测模型。结果术后1个月、3个月时患儿左心室舒张末径、肺动脉内径、肺动脉瓣血流速度明显低于术前;主动脉瓣口血流速度明显高于术前(P<0.05)。100例行改良修补术患儿共15例(15.00%)发生术后心律失常、85例(85.00%)未发生;对两类患儿进行分组观察临床各项参数显示,年龄、采用修补类型、修补直径、术前心律失常、手术时间、术前肺动脉内径、术前肺动脉瓣血流速度是导致心律失常发生的可疑影响因素(P<0.05)。进一步logistic回归分析显示,年龄、手术修补类型、修补直径、术前心律失常、手术时间是导致术后并发心律失常的主要影响因素(P<0.05)。根据回归系数拟合所得出的联合数据进行ROC分析显示,联合预测模型的预测AUC为0.980;预测敏感度93.3%、特异度98.8%。结论儿童室间隔缺损患儿采用改良修补术后,心功能恢复较佳。术后早中期并发心律失常的主要因素包括年龄、手术修补类型、修补直径、术前心律失常、手术时间;临床对此要予以重视。

Feasibility analysis of rapid right ventricular pacing in thoracic endovascular aortic repair under local anesthesia

Background Rapid right ventricular pacing is one of the methods for counteracting the ＂wind sock＂ effect in the thoracic endovascular aortic repair （TEVAR）. Most of the doctors are to complete this operation under general anesthesia. Now, our operation has been performed under local anesthesia. No related reports were found as to whether can the patient tolerate rapid fight ventficular pacing under local anesthesia. Methods From 2009 January to 2010 January, in our hospital all the DeBakey llI aortic dissection patients who underwent TEVAR were randomly divided into general anesthesia group （n = 50） and local anesthesia group （n = 51）. All the data were compared between two groups including the hemodynamic indexes, the graft positioning accuracy, rapid pacing duration, operation time, intraoperative discomfort and postoperative neurological understanding function changes and the complications. Results The success rate were 100% in the two groups. The duration of rapid pacing, operation time, the accuracy of graft localization and the intraoperative discomfort scores of Numerical Pain Rating Scale showed no significant difference between the two groups （P 〉 0.05）. There were no rapid fight ventricular pacing-related complications in the two groups. Conclusion During thoracic endovascular aortic repair procedure, rapid fight ventricular pacing under local anesthesia is safe and feasible. Thus it is worthy to be popularized in clinical practice.

Ebstein畸形的外科治疗

目的探讨手术治疗Ebstein畸形的临床疗效。方法1992年7月至2006年4月手术治疗12例Ebstein畸形的患儿,其中男8例，女4例；年龄：13个月～10岁，平均（70±32）月；体重：8．5～27kg，平均（16．8±6．4）kg；术前SPO2 85％～98％，平均（92±4）％，2例心功能Ⅰ级，7例心功能Ⅱ级，3例心功能Ⅲ级，心超均示三尖瓣重度反流；全组行三尖瓣整形术，房化右心室折叠，同时关闭房间隔缺损，其中2例行一室半手术。结果术后无死亡，复查心超示三尖瓣反流改善，胸片示心脏缩小。术后随访1个月～7年，平均（38±20）月，2例三尖瓣反流加重，心功能不全，均再次手术，1例于术后3年行三尖瓣置换术，1例于术后7年行一室半术，术后心功能恢复至I级。结论Ebstein畸形是一种少见的先天性心脏病，三尖瓣成形术能明显改善三尖瓣反流，保护右心功能，同时可根据三尖瓣和右心室发育情况决定是否行一室半术。

右外侧小切口室间隔缺损修补术疗效及生活质量研究

目的评价右外侧小切口室间隔缺损修补术的疗效及术后生活质量。方法488例调查年龄为6-15岁的右外侧小切口室间隔缺损修补术为右侧组,随机抽取同期185例调查年龄为6-15岁的正中开胸室间隔缺损修补术为正中组。比较2组近期疗效、远期疗效和术后健康相关生活质量,近期疗效指标包括体外循环时间、心肌阻断时间、术后胸液量、院内死亡、并发症情况及术后住院时间,远期疗效指标包括远期症状、体征、超声心动图、胸片、心电图检查结果,术后健康相关生活质量以中文版TACQOL（TNO-AZL Children’s Quality of Life）量表评价。结果右侧组胸液量明显少于正中组[（106.7±85.2）ml vs.（146.7±75.6）ml,t=5.603,P=0.000]。2组体外循环时间、主动脉阻断时间、术后住院时间、院内死亡率、并发症发生率无统计学显著性差异（P〉0.05）。2组鸡胸发生率[0 vs.1.6%（3/185）,χ^2=413.041,P=0.000]、TACQOL量表中身体状况[（29.6±2.8）分vs.（28.1±3.0）分,t=4.843,P=0.000]、运动功能[（31.2±1.1）分vs.（30.5±1.6）分,t=5.139,P=0.000]、自理能力[（31.9±0.4）分vs.（31.6±0.8）分,t=5.130,P=0.000]、认知能力[（29.9±3.2）分vs.（26.9±4.2）分,t=7.902,P=0.000]、积极情绪[（13.4±2.2）分vs.（12.6±2.1）分,t=3.394,P=0.000]差异显著,右侧组优于正中组。远期疗效的其他指标和TACQOL量表中其他维度2组间无统计学显著性差异（P〉0.05）。结论右外侧小切口室间隔缺损修补术疗效满意,术后生活质量更佳。

室间隔缺损修补后残余漏的外科治疗(附18例报告)

目的 探讨先天性室间隔缺损(VSD)修补后残余漏的手术疗效及预防VSD残余漏的要点。方法 回顾分析了我院19年内收治的VSD修补术后发生残余漏再次手术18例,均为先天性膜部VSD,首次手术中缺损直接缝合修补者4例(直径<1.0cm),1例术中停体外循环后发现右室表面震颤,立即再次修补,3例术后早期分别因血红蛋白尿、严重心脏杂音及心功能不良再次手术。首次手术中缺损采用补片修补(直径>1.0cm)14例术后晚期(>6个月)再次手术,除一例仅因心脏杂音外,其余均因有程度不同的临床症状及X线胸片示心影大、肺血多,ECG示左室肥厚等表现和超声心动图示VSD残余分流明显。结果2例死亡,2例仍存在残余漏,14例痊愈。结论 良好的术野显露、准确的手术操作及丰富的手术经验是防止VSD修补后残余漏的主要因素。再次手术应严格掌握指征,手术的关键在于避免损伤性大出血及准确地修补残余漏。