| Backgrounds:Congenital heart disease (CHD) has become the most common congenital deformity leading to neonatal death in recent years. The latest statistical data demonstrate that 8 to 12 out of the 1000 live birth infants suffer from CHD in the world. In China, the morbidity of CHD among the 1-year-old infants has increased year by year to 1.11%, among which, ventricular septal defect (VSD), patent ductus arteriosus (PDA) and atrial septal defect (ASD) are the three kinds of most common CHDs. Some patients usually have the combination of two or above cardiac abnormalities, and patients that have two or above types of concurrent cardiovascular diseases or abnormalities that require treatment have combined CHD.Combined CHD is not rare and approximately 50% of surgically treated VSD cases have other concurrent abnormalities.6% of these cases have combined large or moderate PDA, among which 25% have cardiac insufficiency; 17% cases have combined ASD; and 10% of the patients with ASD have combined pulmonary stenosis, 5% have combined VSD, and 3% have combined PDA. VSD combined with ASD, ASD combined with PDA, and VSD combined with PDA are considered to be the severe complicated abnormalities. Some infant patients have severe pulmonary congestion status, which should be paid enough attention to and requires early correction.Open heart surgery under general anesthesia and cardiopulmonary bypass is the gold standard for treating CHD; however, such treatment is associated with many drawbacks, such as the requirement of cardiopulmonary bypass and aorta clamp blocking, great operation injury, and long recovery time. The percutaneous intervention method for treating CHD has been developed gradually under such background. However, this intervention method also has notable disadvantages; for instance, it requires long-term cardiac catheterization and radiation exposure, increases the risk of atrioventricular block, damages the aorta and cardiac valves, and has high requirements on the patients’ vascular access conditions.With the continuous development of the new technical expertise in the past two decades, the transthoracic small incision occlusion under the esophageal ultrasound guidance has been rapidly developed and become the new option for treating CHD. Plenty of the previous literature reports have verified the safety and effectiveness of such novel technique in treating single CHD (single VSD, PDA and ASD in particular). But there is little research regarding the application of such method in treating the combined CHD during corresponding period, and there is no clear conclusion in terms of the precise surgical method and route.Objectives:This research comprehensively concluded and analyzed the surgical method of transthoracic small incision occlusion under the esophageal ultrasound guidance in treating combined CHD, as well as the surgical feasibility and safety; compared the merits and demerits of several different surgical schemes, with an aim to provide reference for the clinical promotion of the transthoracic small incision occlusion under the esophageal ultrasound guidance in treating combined CHD.Methods:Altogether 60 cases of combined CHD patients received the transthoracic small incision occlusion under the esophageal ultrasound guidance from February 2010 to July 2016, among which 25 were male and 35 were female, with the age ranging from 4 months to 39 years, and the median of 35.5 months.17 cases were less than 1 year old (28.3%), and 34 had the age of 1 to 5 years (56.7%). The body weight of the patients ranged from 5.5 to 65kg, with the median of 13kg.27 cases were VSD combined with ASD,16 were VSD combined with PDA,15 were PDA combined with ASD, and 2 were VSD combined with ASD and PDA through the transthoracic echocardiography diagnosis.41 out of the 45 cases of combined VSD patients had perimembranous VSD, and 4 were subarterial VSD; 44 cases had combined secundum ASD and 2 had diapsid ASD.31 of the 33 combined PDA patients had tubular PDA,1 was window type PDA and another 1 had funnel-shaped PDA. The atrial and ventricular septal shunt signals were the left-to-right shunt. No moderate or severe cardiac valvular regurgitation or cardiac valvular organic diseases could be seen.The inclusion and exclusion criteria of patients:1. the inclusion criteria:(1) a clear diagnosis with well-defined ASD, VSD and PDA through echocardiography, and had the possibility of occlusion; (2) with no other cardiovascular abnormalities that required CPB surgery for correction during the corresponding period.2. The exclusion criteria:(1) a clear diagnosis with obvious valve prolapse or moderate or above regurgitation; (2) patients with other combined CHDs that required surgery under cardiopulmonary bypass; (3) CHD patients with single abnormality; (4) a clear diagnosis of Eisenmenger’s syndrome or the color Doppler flow imaging in the transthoracic echocardiography revealed right-to-left shunt in the heart defect; (5) uncorrected cardiac failure before surgery; (6) infectious endocarditis with neoplasm within the heart chambers; and (7) patients with contraindications of anticoagulation and anti-platelet.The surgery was implemented under general anesthesia and tracheal intubation. The type, size and margin of the cardiac abnormalities were determined through transesophageal echocardiography preoperatively, and the entire occlusion process was monitored in real time. The appropriate occluder and delivery system were selected for use according to the transesophageal echocardiography results.The patients were divided into 4 groups in accordance with their different combined abnormalities; group 1 was VSD combined with ASD, group 2 was VSD combined with PDA, group 3 was ASD combined with PDA, and group 4 was VSD combined with ASD and PDA.Various surgical incisions and surgical routes were selected based on the diagnosis, type and site of the cardiac abnormalities in patients, as well as the combinations of the combined abnormalities, and the difficulty of occlusion; patients in group 1 adopted the right thorax-right atrium route, middle inferior segment of sternum-right ventricle route, right atrium route, and left thorax-right ventricle combined with percutaneous intervention route, respectively; group 2 adopted the middle inferior segment of sternum-right ventricle route and the pulmonary artery route; group 3 utilized the left thorax-pulmonary artery combined with right thorax-right atrium route; and group 4 took the middle sternum-right ventricle, right atrium and pulmonary artery routes.Follows-up were conducted 1,3,6 and 12 months after surgery as well as once every year afterwards. The occluder position and stability, with/without residual shunt or new cardiac valvular complications induced by the occlusion were evaluated.SPSS 19.0 statistical software was applied in the statistical analysis on all data. The numerical variable data were expressed as median or X ±s. The one-way analysis of variance F test or chi-square test was applied in the pairwise comparison between all observation indicators. The significant level was set at 0.05, the P value was adopted in result comparison, and difference with P>0.05 was considered to be of no statistical significance, while difference with P<0.05 was of statistical significance.Results:Occlusion was successfully performed in all the 60 cases of combined CHD patients in this research (100%), altogether 122 occluders were successfully implanted, 55 cases (91.7%) had successful one-time implantation of the occluders, and the successful one-time implantation rate of the 122 occluders reached 95.9%. The average duration of operation of all patients was (77.9 ±28.9) min (42-165min); and the occlusion time of VSD, ASD and PDA was (12.1±9.8) min (4-55min), (7.0±4.0) min (2-17min) and (7.4±4.4) min (2-17min), respectively.Extubation was conducted within 24h after the surgery, the assisted respiration duration was (226.1±172.8) min (79-1020min); the ICU observation time was (20.3±5.0) h (16-39h), and the postoperative length of stay was (5.4±1.5) d (3-8d).No ASD or PDA residual shunt was seen on transthoracic echocardiography during the follow-up period.3 cases had residual shunt after VSD occlusion, which disappeared within 3 months to 1 year during the follow-up.3 cases had new aortic regurgitation postoperatively,2 had mild mitral regurgitation, and 2 had tricuspid regurgitation.2 patients developed incomplete right bundle branch block after occlusion, which disappeared in the third month after surgery and returned back to the normal electrocardiography. No patient had a second surgery during the follow-up period.The occurrence rate of severe complications was 0, including infectious endocarditis, atrioventricular block, thromboembolism, aortic valve and atrioventricular valve injury, and death. No displacement of the occluders, and no surrounding tissue injury was seen.Conclusions:This research verified the feasibility of transthoracic small incision occlusion under the esophageal ultrasound guidance in treating combined CHD, which does not increase the risk of surgical complications or reduce the success rate of occlusion. The key of transthoracic small incision occlusion under the esophageal ultrasound guidance lies in the flexible selection of various surgical routes, adjustment of the occlusion order based on the different cardiac abnormality combinations, the skilled performance of the operators, the accurate evaluation of the sonographers and the convoy of the detailed and efficient alternative scheme.The transthoracic small incision occlusion under the esophageal ultrasound guidance in treating combined CHD has marked advantages over other treatments, which are as follows:it requires no cardiopulmonary bypass compared with the traditional surgical procedures, with small incision, small wound, short duration of operation, short assisted respiration time, short postoperative recovery time and little complications; it needs no X-ray exposure or contrast agent, with no body weight or age limitation, no blood vessel condition limitation, with simple and easy to learn occlusion method relative to the intervention method, and surgical procedure can be altered rapidly in the case of failed occlusion, so as to guarantee the patient safety. Despite the above merits, it still has some demerits, which are that it requires intraoperative tracheal intubation and general anesthesia; sometimes 2 surgical incisions are required, and some cases require sternotomy, which increases the surgical wound.The surgical schemes for patients with VSD combined with ASD are decided mainly based on the position and morphology of the VSD as well as the difficulty in occlusion. The right thorax-right atrium puncture point surgical method is adopted in patients that have combined perimembranous VSD with the diameter of between 2.0 to 7mm, or combined intermediate muscular VSD, or require no placement of the eccentric occluder. Median sternotomy incision, occlusion of VSD through the right ventricle, and occlusion of ASD though the right atrium are recommended for patients with combined perimembranous VSD with the diameter of <2.0mm or >7mm, or with apical VSD. The left thorax-left ventricle route for the occlusion of VSD, and the right thorax-right atrium or percutaneous occlusion of ASD is selected for patients with combined subarterial VSD. Small trauma, no need of longitudinal split of sternum, and single puncture point are preferred in selecting the surgical scheme.We decide the occlusion order in accordance with the difficulty of cardiac abnormality correction and risk of occlusion complications. Generally speaking, the defect with the highest difficulty and risk is occluded first. Repair under cardiopulmonary bypass and direct vision should be conducted as early as possible in the case of failed occlusion.Although the results in this research are encouraging, it is still associated with drawbacks like small sample size, short follow-up period and non-randomized controlled trial. |
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