Urgent Or Emergency Surgical Treatment Of Ventricular Septal Defect With Severe Performance In Infants Under 6 Months

Objective1.To summarize the experience of urgent or emergency surgical treatment of ventricular septal defect with severe performance in infants;2.To emphasize and adjuste the preoperative status of the children,and stress the potential risk of pulmonary and bronchial lesions;3.For critically ill children with congenital heart disease,it is necessary to develop individualized treatment plan,grasp the adaptation strictly and improve the operation effect,to avoid or reduce postoperative complications.Methods A retrospective analysis in the data of urgent or emergency surgical treatment of ventricular septal defect under 6 months with severe performance from february 2003 to december 2015.The whole set of 534 cases,332 cases of male,female 202 cases,the age was from 20 days to 6 months(4.0±1.3)and the weight was from 3.1 to 7.0 kg(5.5±1.2),with above moderate pulmonary hypertension;partly mergering atrial septal defects,patent ductus arteriosus,aortic coarctation,above moderate mitral regurgitation,right ventricular outflow tract obstruction and diarrhea,severe malnutrition,thrush,throat singing and asthma,etc.We used the examination of echocardiography or MRI or 64-row CT to determine the diagnosis before opration.The group were associated with continuing,or repeatedly,or severe pulmonary infection and cardiac insufficiency,different degrees of fever,cough and asthma,flustered and exasperated,dyspnea,moist rale and/or wheezing rale,hepatomegaly,fast heart rate and facial edema,etc.The result of preoperative sputum cultures of partial patients was positive,including enterobacter(enteroaerogen,polybacillus,cloacae),staphylococcus aureus,klebsiella pneumoniae,mycete,streptococcus(hemolytic and grass green),pseudomonas aeruginosa,acinetobacter baumannii,e.coli.2 blood cultures were positive(epidermis staphylococcus aureus and imitated staphylococcus aureus).They were treated in pediatric,Cardiology,PICU,NICU for 7 ~ 60 days(20.6±10.3),partial patients were used by ventilator,then shifted to cardiac surgery directly when they were improved or not,of which 8 cases shifted to the operating room with tracheal cannula.We used endotracheal intubation,combined intravenous-inhalation anesthesia,membrane oxygenation,shallow or medium-low temperature bypass and improved ultrafiltration.Ventricular septal defects were repaired by auto pericardium patch continuouly or discontinuouly,processing combination of other deformity at the same time,such as PDA ligation,ASD closure,removal of the Co A then end to end or end to side anastomosis or Gore-Tex expansion,constrict plastic of mitral valve,etc.Membrane oxygenation and ultrafiltration were used,and the erythrocyte increased to(34.7±1.2)%.The piezometer tube of left atrial,right atrial and pulmonary artery and the temporary pacing leads were used conditionally and the combined application of dopamine,miriam,adrenalin and other drugs in intraoperation and postoperation,they were all treated in CICU.Results The whole group with aortic cross-clamping time was(24~93)(34.34 4 ± 30.24)min,extracorporeal circulation time was(34~196)(54.28 ± 60.43)min,time for postoperative ventilator support was(10 ~ 391)(98.21±100.36)h,and length of ICU was(4 ~ 19)(7.25±12.94)d.Reference to the American thoracic society(STS)and European association for thoracic surgeons annual meeting(EACTS)about the definition of recent death,there were 17 died cases in the intraoperative and recently postoperative,mortality rate was 3.2%(17/534),including 8 cases of male,9 cases of female,the age from70 days to 6 months and the weight from 3.1 to 7.0 kg,preoperative with tracheal stenosis 5 cases,4 cases of severe pneumonia.1 case with right ventricular hypoplasia could not stop the CPB,died in intraoperation,1 case died due to multiple organs function failure in the secondary sternal closure after five days of delayed sternal closure,1 case died due to cardiac failure in the secondary surgery because of tension pneumothorax,another 1 death caused by cardiac failure because of postoperative pulmonary hypertension crisis and tricuspid regurgitation,1 case died of streptococcus infection severely after operation,the rest 12 cases were died of low cardiac syndrome after operation.There were 480 cases who were cured or continued the treatment after basic rehabilitation.Among them,postoperative ventilator assisted time were(41.0±58.0)h,the longest was 20 days;11 cases weaning from mechanical ventilation were failed,and then intubated,one of them was reintubated four times.The length of ICU were(3.6±2.9)d,8 of them returned to ICU because of poor condition out of ICU,the longest one was 43 days.Conclusion Urgent or emergency surgical treatment of ventricular septal defect with severe performance in infant was safe,but the adjustment of preoperative status could not be ignored,especially the situation of the lung and the bronchus.The condition of critically ill children with congenital heart disease should be analyzed concretely and set out individualized treatment options,to improve the level of surgery,anesthesia and extracorporeal circulation,and grasp the adaptation of the postoperative care are very important.