Physiological correction of transposition of great arteries combined with intracardiac deformity correction

Congenital correction of transposition of the great arteries is defined as a cardiac malformation in which the atrial and ventricular and ventricular and aortic connections are inconsistent. These two connections are inconsistent to produce normal and tandem body and pulmonary circulation pathways. Systemic venous blood flows into the right atrium, through the mitral valve and the left ventricle to the pulmonary artery; pulmonary venous blood flows into the left atrium, through the tricuspid valve and the right ventricle to the aorta, thereby being physiologically corrected, so this deformity is also called physiological Correct the transposition of the great arteries. The majority were atrial orthotopic SLL type, and a few were atrial retrograde IDD; more than 90% of patients had ventricular septal defect, pulmonary stenosis, tricuspid regurgitation and complete atrioventricular block. Treatment of diseases: ventricular septal defect ventricular septal defect Indication 1. Anatomical correction surgery: This operation includes intra-atrial transfer and aortic transfer or Rastelli surgery, also known as double-switching. The operation is to pass the systemic venous blood flow through the tricuspid valve and the right ventricle to the pulmonary artery; the pulmonary venous blood flow through the mitral valve and the left ventricle to the aorta, thereby physiologically correcting the transposition of the great artery to obtain an anatomical correction. The basic requirement for double-transfer surgery is a left ventricular/right ventricular systolic pressure ratio >0.70, normal left ventricular development and function, good pulmonary artery development and/or coronary artery distribution. (1) ventricular septal defect: in the neonatal period, there is a large ventricular septal defect and pulmonary blood in the first to do pulmonary artery contraction, 12 months after birth to perform double-transfer surgery; no pulmonary blood flow is excessive, then in Surgery 3 to 12 months after birth. At this time, the right atrium is large enough to perform intra-atrial transfer. In patients with heart failure in infants, pulmonary vascular resistance is gradually increased by cardiac catheterization, and double-transfer surgery should be performed as soon as possible. (2) Simultaneous ventricular septal defect and pulmonary outflow tract obstruction: atrial transposition and Rastelli surgery should be performed after 5 years of age. A small number of small infants with severe pulmonary outflow obstruction or pulmonary atresia, because the ventricular septal defect can be smaller, should be performed as soon as possible. Adults with right ventricular dysfunction and moderate to severe tricuspid regurgitation develop heart failure, and double-transfer surgery should be performed at an elective stage. After the double-transfer surgery, the right ventricle became a pulmonary blood pump, the right ventricular function was improved, and the tricuspid regurgitation was significantly relieved, which is unmatched by traditional intracardiac repair surgery. In patients with Ebstein's cardiac malformation, tricuspid valve replacement was performed during the operation, and the tricuspid regurgitation disappeared after operation. Double-transfer surgery is a newly-developed operation, and its surgical indications are still expanding. Clinically, double-transfer surgery and bi-directional pulmonary artery shunt are used to treat this deformity with right ventricular dysplasia. Double-transfer surgery combined with complete pulmonary veins Ectopic connection, plus Damus-Kaye-Stansel for the treatment of small ventricular septal defect and pulmonary stenosis. 2, traditional intracardiac repair: congenital correction of large artery transposition with pulmonary outflow tract blockage and / or small ventricular septal defect, can not be double-transfer surgery, the left ventricle to the pulmonary extracardiac duct. A small number of pulmonary stenosis only, the use of pulmonary valve incision. Contraindications 1. A small number of congenital correction of aortic transposition with aortic atresia, often accompanied by severe tricuspid regurgitation, thin-walled ventricle and right ventricular dysfunction similar to Ebstein's cardiac malformation, not suitable for intracardiac repair and Damus-Kaye-Stansel surgery Heart transplantation should be considered. 2, the two ventricles have severe dysfunction or hypoplasia. 3. There is severe liver and kidney dysfunction. Preoperative preparation 1, neonates and small infants with large ventricular septal defect with congestive heart failure, with digitalis and diuretics, and cardiac catheterization. If the medical treatment is ineffective or the pulmonary vascular resistance is gradually increased, surgery should be performed as soon as possible. In patients with lower left ventricular pressure, pulmonary artery contraction was performed first. After 6-12 months of cardiac catheterization, the left ventricular/right ventricular systolic pressure ratio was >0.70, and double-transfer surgery was performed. 2. In patients with ventricular septal defect and pulmonary outflow tract obstruction, preoperative echocardiography should be carefully examined for mitral paravalvular or ventricular septal bulging tumors resulting in left ventricular outflow tract obstruction. Cardiovascular angiography showed better development of bilateral pulmonary arteries, McGoon ratio 1.5, pulmonary artery coefficient 180mm2/m2, and double-transfer surgery after 5 years old. Before the age of 5, the stenosis was severe, and the subclavian artery and pulmonary artery shunt were first modified. 3, combined with severe tricuspid regurgitation and heart failure, preoperative application of digitalis and diuretics, elective double-transfer surgery, intraoperative tricuspid valve repair, a small number of tricuspid valve replacement. 4, combined with complete pulmonary venous connection, should do cardiovascular angiography, understand the location of the venous connection of the pulmonary veins and intracardiac malformation, in order to develop a surgical plan. 5, combined with right ventricular dysplasia, such as right ventricular dysplasia is relatively light, can do double-transfer surgery and (or) two-way cavity pulmonary shunt. Otherwise, Fontan surgery should be considered. 6, combined with pre-excitation syndrome, preoperative ECG should be done to determine the location of the abnormal atrioventricular conduction beam. Prepare the epicardial mapping before surgery. 7, need to do Rastelli surgery, preoperative preparation of the same kind of valved aorta; tricuspid valve replacement to prepare the appropriate type of bilobal mechanical valve. Surgical procedure A midline incision in the chest removes the thymus. The ascending aorta was inserted into the arterial infusion tube, and the superior and inferior vena cava tubes were directly inserted. After the cardiac arrest, the left heart decompression tube was inserted through the patent foramen ovale or the interatrial septum incision, and the following operations were performed. 1, anatomical correction surgery or double conversion surgery Patients undergoing congenital correction of transposition of the great arteries should be treated according to their combined malformation and right atrial size. In general, in patients with large ventricular septal defect, the shape of the pulmonary valve is normal, the size and function of the left ventricle are normal, and the two atriums are large enough. Senning surgery and aortic transposition should be performed. In the SLL type or IDD type, the right or left heart is combined, and the modified Senning operation and the aortic transfer are applied. In patients with ventricular septal defect and pulmonary outflow tract obstruction, Senning or modified Senning and Rastelli surgery were performed. (1) Senning and aortic transposition 1 The right atrial longitudinal incision and the left atrial incision of the sulcus were made 1.0 to 1.5 cm before the final sac, and the upper and lower ends of the right pulmonary vein reached the upper and lower margin planes. 2 Repair of the large ventricular septal defect through the right atrial incision and the mitral valve orifice. The cut polyester patch is round and the patch is slightly smaller than the defect. Use a 4-0 or 5-0 double-ended needle with a gasket to make a ring with a gasket-type suture, and the front upper edge of the defect is sewn to the right ventricle surface 2 to 3 mm from the edge of the defect. The other edges are sewn on the left side of the heart to avoid heart block, and each stitch is sewn through the edge of the patch and pushed down for ligation. Regarding the surgical sequence of intra-aortic and aortic transposition, the opinions of each family are inconsistent. Most of them do intra-atrial transfer surgery, and then the aortic transfer surgery; a few do the aortic transfer, and then the intra-atrial transfer. 3 first in the atrial transfer surgery, through the right atrial longitudinal incision, longitudinal incision of the interatrial septum leading edge, cut at both ends into a trapezoidal incision. The atrial septum or a polytetrafluoroethylene patch was sutured to the left atrium of the left pulmonary vein and the posterior wall of the left and right left atrium to separate the pulmonary vein from the left tricuspid valve. 4 The posterior margin of the posterior margin of the right atrial incision was sutured to the anterior border of the atrial septal incision and the upper and lower margins of the atrial septal defect were sutured to the superior and inferior vena cava openings, thereby establishing a vena cava to the left tricuspid and right ventricular channels, coronary veins. The sinus opening is placed on the newly established left atrial side. 5 The right atrial longitudinal incision was used to sew to the posterior margin of the left atrial incision of the chamber ditch to form a new left atrium, which were sutured continuously with 4-0 or 5-0 polypropylene thread. At this time, a transverse incision is made at the upper end and the lower end of the right atrial incision leading edge, and the edge is sutured around the sinus node to the left atrium to avoid damage of the sinus node. Then do aortic transfer. 6 The ascending aorta and pulmonary trunk were transected separately above the aortic sinus-tube junction and below the pulmonary bifurcation. In most cases, Lecompte is required, in which the pulmonary artery and its bilateral pulmonary arteries are placed in front of the aorta. The malformed coronary artery is distributed in the reverse position of the normal heart, so a U-shaped incision should be made in the right posterior sinus and the left posterior sinus, respectively, and the U-shaped aortic coronary artery piece containing the coronary artery opening should be transplanted to the corresponding part of the adjacent pulmonary artery. First, the left side and the back side were anastomosed, and they were sutured continuously with a 6-0 or 7-0 polypropylene thread. The distal end of the aorta is anastomosed to the proximal end of the pulmonary artery. 7 Use the pericardium to repair the proximal U-shaped incision of the aorta and enlarge the distal aorta of the aorta and the pulmonary artery. This completes the double-tuning of this deformity. The following lesions may be encountered during this malformation: a. pre-excitation syndrome; b. left or right atrioventricular valve malformation; c. right ventricular outflow tract stenosis or tricuspid lobes or interventricular septum Pulmonary artery outflow tract obstruction caused by bulging tumor should be treated simultaneously during surgery. (2) Mustard and Rastelli surgery 1 right atrial incision through the parallel interventricular septum. 2 According to the conventional method, Mustard operation was performed to remove the interatrial septum. The autologous sac was used to drain the vena cava blood through the tricuspid valve to the right ventricle and pulmonary venous blood through the mitral valve to the left ventricle. If the right atrium is small, it can be expanded with glutaraldehyde-treated pig pericardium and horse pericardium. 3 The right ventricle longitudinal incision was made to fully reveal the ventricular septal defect. The lower edge of the defect was made through the root of the tricuspid valve and surrounded by the edge of the defect and the aortic annulus. Pass the needle through the edge of the oval polyester patch and push down the ligation. 4 The longitudinal incision of the pulmonary artery was performed, and the pulmonary valve was sutured through the incision, and the right ventricle to the pulmonary artery of the same kind of aortic valve was performed. Thus, the right ventricle blood is discharged to the pulmonary artery through the extracardiac tube, and the left ventricular blood passes through the intracardiac tunnel to the aorta, thereby correcting the transposition of the large artery to obtain an anatomical correction. In the SLL type of corrective aortic transposition combined with ventricular septal defect and pulmonary stenosis or atresia, left heart or combined with right atrial isomerism or right-handed heart can be used to treat the right aortic to the left aortic to the pulmonary artery with extracardiac catheter, avoiding extracardiac catheter Under pressure. Correction of large in situ ventricular septal defect and aortic stenosis in SLL-type corrective aorta transposition with Mustard surgery, ventricular septal defect repair and Damus-Kaye-Stansel surgery, and anti-C-shaped right ventricle to pulmonary extracardial valve . In the IDD type of corrective transposition of the great arteries, left or right atrial isomerism combined with ventricular septal defect and pulmonary atresia, a C-shaped right ventricle to pulmonary artery with extracardiac catheter is performed. 2, traditional intracardiac repair (1) ventricular septal defect repair surgery: in the case of SLL type corrective aortic transposition, routine right atrial incision, exploration for the presence or absence of foramen ovale; exploration of the pulmonary valve through the right atrioventricular valve (mitral valve) , the presence or absence of stenosis under the annulus and flap, and the location of the ventricular septal defect. When the mitral valve is pulled upward, the ventricular septal defect is located behind the small valve and is the same as the general inflow ventricular septal defect after the septum. Most need to make a small incision in the small incision 2mm from the annulus. Super mitral anterior junctional tissue is sometimes required to fully reveal the overall appearance of the ventricular septal defect. The application is repaired with a large PTFE round patch such as a ventricular septal defect. The anterior and posterior margins of the ventricular septal defect were sutured to the right ventricular surface of the septum, and the other margins were sutured to the left ventricle. They were sutured with a lap-type suture, and then passed through the edge of the patch to push down the ligation. The infants and young children can be sutured with 5-0 polypropylene thread for ventricular septal defect patch repair, and also in the danger zone to the right ventricular surface. The mitral valve edge incision was sutured later using a 5-0 polypropylene thread. In the case of ventricular septal defect in this type of malformation, a small number of cases can be repaired through the mitral valve orifice without mitral incision. In the repair of IDD-type ventricular septal defect, the left ventricular longitudinal incision was made through the left ventricular longitudinal incision, and a sacral suture was placed on the left ventricular surface at the edge of the ventricular septal defect. The dangerous area was sutured in the anterior mitral valve root and the ventricular septum. After the ventricular surface passes through the edge of a large circular patch with a defect, the ligation is pushed down. Infants and young children can also be sutured continuously with 5-0 polypropylene thread to repair the patch of ventricular septal defect. There are also very few cases, the ventricular septal defect is small, the diameter is about 0.5cm, whether in the SLL type or IDD type can be right ventricular incision in the fiber ring around the defect to make a discontinuous band suture suture to close the defect. (2) Pulmonary valve incision or left ventricle to pulmonary extracardiac catheter: It is necessary to be particularly careful when deciding to perform only pulmonary valve incision. Because of the correction of transposition of the great arteries with pulmonary stenosis, the pulmonary valve often has two leaflets, a single leaflet or an annulus and subvalvular stenosis. After the longitudinal incision of the pulmonary artery, it is necessary to explore it carefully. After the incision of the pulmonary valve junction, the pulmonary artery outflow tract is also explored. After the obstruction is fully relieved, the pulmonary artery incision is sutured. Only pulmonary valve incision, often can not fully remove the obstruction, especially the pulmonary outflow tract spiral, if the muscle hypertrophy can pass the appropriate size of the probe under myocardial relaxation, but after the heart jumps, it will produce serious Blocked. Therefore, in the treatment of pulmonary stenosis, there can be no luck, more should be used to the left ventricle to the pulmonary extracardiac duct. Especially after stopping the extracorporeal circulation, when the pressure measurement shows that the left ventricular/right ventricular systolic pressure ratio is >0.75, it is necessary to re-perfuse the left ventricle to the pulmonary artery. The extracardiac duct from the left ventricle to the pulmonary artery should generally be administered after the age of 5, and the same type of aortic valve can be used to obtain a satisfactory long-term effect. A longitudinal incision of the pulmonary artery is made and extended to the bifurcation of the pulmonary artery, and the pulmonary valve orifice is sutured through the incision. The right atrial incision was used to probe the anterior and posterior papillary muscles of the mitral valve, and a left ventricle longitudinal incision was made between the two. The distal end of the same aortic valve was cut into a bevel and the endoscopic anastomosis of the pulmonary artery was performed. The 5-0 polypropylene line was used to make the close suture of the left edge of the right edge of the incision. The connected polyester vessels of the same aortic annulus were cut into a bevel and a left ventricular incision for end-to-side anastomosis. Finally, the SLL-type extracardiac tube is C-shaped, and the IDD type is anti-C-shaped to prevent sternal compression. Open the window through the pericardium, and do the right chest closed drainage. (3) Repair of ventricular septal defect and left ventricular to pulmonary extracardiac: In patients with ventricular septal defect and pulmonary stenosis, the right ventricular approach is used to repair the ventricular septal defect, and then the left ventricle to the pulmonary artery A valved aorta. (4) atrial septal defect repair: through the right atrial incision, directly suture the atrial septal defect, such as a large atrial septal defect or combined right plexus ectopic connection to the right atrium, then do the pericardial patch repair. 3, the treatment of malformation (1) Arterial catheter ligation: In the SLL type of corrective aorta transposition, the patent ductus arteriosus is located on the right side, and the IDD type is located on the left side. It is difficult to find the patent ductus arteriosus in the SLL type. The right pulmonary artery after the pulmonary artery bifurcation can be treated with continuous fine tremor. It should be carefully separated and ligated after the flow. In the IDD type, it is handled as usual. (2) Abnormal atrioventricular conduction beam severing: The epicardial mapping is performed before the flow, and the abnormal atrioventricular conduction beam is cut after cardiac arrest. In the case of SLL type corrective aorta transposition, the abnormal atrioventricular conduction beam after the severance is cut, there is no risk of complete heart block. (3) Treatment of left tricuspid regurgitation: In the case of congenital correction of transposition of the great arteries, due to the volume overload of the right ventricle and the volume overload of the ventricular septal defect, the right ventricle and annulus enlargement produce a three-pointed The flap is incomplete and tricuspid annuloplasty is available. For tricuspid dysplasia or Ebstein heart malformation, tricuspid valve replacement is performed. (4) treatment of right mitral valve malformation: mitral valve flap, can be directly sutured; mitral annulus enlargement for annuloplasty; severe mitral dysplasia for valve replacement. (5) Treatment of left ventricular outflow tract obstruction: Intraoperative exploration revealed that the left ventricular outflow tract obstruction due to tricuspid or pulmonary aortic valve, ventricular septal bulging tumor and pulmonary artery annulus should be removed. complication 1. The most common arrhythmia after arrhythmia is i- or II degree atrioventricular block, which is effective with low-dose isoproterenol. Temporary cardiac pacing is applied when complete heart block occurs; permanent cardiac pacemakers are installed if sinus rhythm cannot be restored. A small number of patients have supraventricular tachycardia after double-transfer surgery. You can choose digitalis or beta-blockers, such as propranolol 0.01 to 0.1 mg/kg diluted in 5% glucose solution, 5-10 min. Slow intravenous injection, repeated 6 to 8 hours if necessary, can also receive good results in patients who are not treated with digitalis. Those with atrioventricular block are banned. 2, low cardiac output syndrome SLL type of correctional large artery transposition patients after Rastelli surgery due to placement of the right arrhythmia in the right aortic tube or partial aortic transfusion after partial myocardial insufficiency and block aortic time Myocardial reperfusion injury, etc., often cause postoperative low cardiac output syndrome. The former needs to delay the closure of the chest, while the latter two use small doses of dopamine and (or) dopamine amide and sodium nitroprusside and other vasodilators to improve cardiac output and improve peripheral circulation, in severe cases of left ventricular assisted circulation. 3, hemorrhage due to vascular anastomotic bleeding or artificial blood vessel oozing. The pericardium and chest drainage tube were routinely squeezed after operation. If there is more bleeding or blood clots in the drainage tube or cause cardiac tamponade, you should strive to stop bleeding and stop bleeding when the blood pressure is stable 6 hours after surgery, without delay. When the chest is opened again, it is necessary to investigate whether the blood vessels are anastomosed or not, and if necessary, suture to stop bleeding. If the vascular blood vessels of the polyester are oozing, the hemostatic drug and the pericardium package are used to stop bleeding. 4, a small number of patients with vena cava occlusion in the atrial transfer after the formation of vena cava obstruction, should be confirmed by echocardiography after the obstruction site and re-surgical repair. 5, long-term follow-up after extracardiac obstruction found that patients with chronic heart failure, echocardiographic diagnosis, elective replacement of extracardiac catheter. 6, chronic pericardial effusion and pleural effusion caused by heart failure caused by this complication, should be pericardial or thoracic puncture or closed chest drainage at the same time as medical treatment.

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