Approach Of CPB On Switch-operation In Transposition Of The Great Arteries

Background Complete aorta indexing (transposition of the great arteries, D-TGA) is the complex congenital heart disease which the aorta dissection relations inverts. The aorta petal does not like normally after the pulmonary artery petal right front, but arrived has been right, met the right ventricle; But the pulmonary artery petal is left after the aorta petal, meets the left ventricle. About the atrium ventricle position has not changed, the atrium and the ventricle relations are also unmistakable (S.D.D).The circulation aspect, venous blood through the aorta arrives the whole body the backflow after the right atrium, but the oxygen gathered the blood to return to the left atrium after the pulmonary vein still to leave the pulmonary artery to enter the lung, caused the body circulation and the pulmonary circulation respectively walks each group, loses physiological principle which the circulation mutually handed over. The trouble infant's temporarily survival relies ASD,VSD,PDA and so on the blood stream exchange to attain the oxygen.Complete aorta indexing is the baby time most common purple dark purple congenital heart disease, occupies all congenital heart disease 9.9% , occupies the newborn cynotic first the heart first (20%), born for two months the heart failure first, the baby which first the heart died because of cynotic. Because : (1) before operation of the TGA mortality rate 9.9%, approximately 80% ~ 90% case of illness die in 1 year old; (2) Ventricular septal integrity TGA indexing like in 2 weeks not line of Switch surgery, then the left ventricle function will degenerate, will lose the surgery opportunity;(3) Even if Ventricular septal defect, surpasses a year old of lung blood vessel the obstruction pathological change to be many has reached above the Heath-Edwards three levels, therefore the TGA patient must as soon as possible the surgery. Follow the cardic muscle protection and the new aorta reconstruction technology improvement along with the coronary artery, the artery Switch operation technique (the Switch surgery) widely to use in the TGA .We use the Deep hypothermia low flow, control flow in 50ml/Kg/min, if the flow < 50ml/Kg/min, every 30 minute interrupted high flow high flow perfusion management. Blood gas management temperature decrease period uses PH-Stat. Deep low temperature and ascend temperature period use a-Stat, obtains satisfactory effect. After the operation makes a follow-up visit has not discovered the nervous system illness complication.Materials and Methods A retrospective analysis of the Third Affiliated Hospital of Zhengzhou University, pediatric cardiac surgery, from December 2003 to January 2006, has 11 cases of D-TGA(D-transposition of the great arteries) cardiopulmonary bypass patients, all male. Hospitalized with medical history and Echocardiography, X-ray and ECG, with diagnosis and surgical findings. 20 hours after birth to the age of 3 years, with an average of 7.22±11.62 months. 14Kg to 2.25Kg weight to the average of 5.52±3.33kg . All patients were using deep hypothermic low-flow (DHLF) cardiopulmonary bypass management. CPB use STOCKERT SIII cardiopulmonary bypass machines.All patients used imports membrane oxygenator (Dideco 901 or Medtronic) and imports of Hemoconcentrator (HPH400). Prime solution with lactated Ringer's solution , the solution pre-conflict exhaust, and later to oxygenator on episodes from the lactated Ringer's solution, adding of aprotinin 100,000 units /Kg,plasma 100 ml and 20% human serum albumin 50～100ml, Sou-Medrol 30mg/Kg, phentolamine 0.1～0.2 mg/Kg, lasix 2mg/kg, 5%NaHCO3 3～5ml/Kg, heparin 20mg. Switch to maintain adequate blood flow HCT 20~25%. After anesthesia to reduce the surface temperature to ensure a balanced cooling, at room temperature about 18℃in regulation. Establishment of cardiopulmonary bypass, bypass, if patent ductus arteriosus(PDA), it started to cool down after the ligation.Rectal temperature of 30℃by adding protective drug propofol or thiopentone. Nasopharyngeal temperature cooled to 18℃, 20℃of rectal temperature and which was around 35～50ml/Kg/min adjustment perfusion flow.Blood gas Mangemant Intraoperative: electrolytes, HCT, and ACT etc, PH-STAT used during cooling and hypothermia,andα-STAT after warming. The CUF to upgrade HCT after warming, and eliminate some of inflammatory cytokines and water. Rectal temperature of 36.5℃following the modified ultrafiltration (MUF), the flow range of 10～40ml/Kg/min and time 10～15min. Cardic muscle protection method: Deploy the American Boston heart center young child's myocardial preservation formula: protection of children with special liquid myocardial retain ice water, the first volume 15ml/Kg antegrade aortic root, if possible halving every 20 minutes after reperfusion. Children age, weight, cardiopulmonary bypass time, the amount of liquid used, etc., the data were statistically with SPSS 10.0 for Windows.RESULTS The transposition of the great arteries for Swith-operation in 11 patients, 10 cases autokinetic subsultus and one defib subsultus. Three patients died, the survival of eight cases, survival rate of 72.7%, mortality 27.7%. Before aortic cross-clamping time 16.33±10.73 minutes. Aortic cross-clamping time 110.33±35.63 minutes, Caval vein open 26.33±12.98 minutes . total cardiopulmonary bypass time 198. 75±31.26minutes. deep hypothermia time 82.00±26.99 minutes. Convention ultrafiltration 32.50±29.95 minutes, filter liquor 341.67±269.10ml. MUF 16.67±2.34minutes, filter liquor 680.00±228.03ml. cardiopulmonary bypass urine average 216.67±157.10ml.Postoperation breathing machine time 72.80±69.40 hour. The hospital two unites blood 2.00±1.262 unit and plasma 583.33±343.03ml. Not have the complications associated with cardiopulmonary bypass.Conclusion 1. Deep hypothermic Low-flow not only supply enough oxygen to patient suffering Switch operation, but also reduce blood cell damage.2. PH-Stat. used in lowing temperature, a-Stat. used in deep hypothermic and warming period is good to brain.3. Modified ultrafiltration technology can promote HCT, heart function, promote blood pressure and reduce ICU time.4. Modified ultrafiltration technology can save blood using, reduce disease transposition through blood.5. Deep hypothermic Low-flow bindine correctly blood gas management and combination of ultrafiltration technology is suitable for the D-TGA surgery.