Dual-Inlet Ventricular Palliative Surgery

The ventricle double entrance is defined as a double inlet atrioventricular connection through the bilateral atrioventricular valve or common atrioventricular valve at both sides of the atrium. In the past, it was customary to call this deformity a single ventricle or a univentricular heart, which is not as good as the ventricle double entrance. The reason is: 1 This deformity is rarely a single ventricle, and often has two ventricles, one of which is The main ventricle, the other is the residual or hypoplastic ventricle; 2 is different from the single ventricular atrioventricular junction with one side atrioventricular valve atresia, such as tricuspid atresia and mitral atresia. Curing disease: Indication 1. In neonates within 1 month after birth, patients with significantly reduced pulmonary blood flow were treated with modified subclavian artery and pulmonary shunt. Excessive blood flow in the lungs, such as no aortic arch obstruction or sub-aortic stenosis, pulmonary artery contraction. If the pulmonary blood flow is excessive and there is aortic stenosis, Damus-Kaye-Stansel surgery and subclavian artery and pulmonary artery shunt should be performed. If there is ascending aorta and aortic arch dysplasia, use Norwood Phase 1 surgery and modified clavicle. Lower arterial and pulmonary shunt. 2, in the age of 4 to 6 months of babies, bidirectional cavopulmonary bypass can be used. In cases of sub-aortic stenosis, two-way cavopulmonary bypass and Damus-Kaye-Stansel surgery can be performed simultaneously. Contraindications In the neonatal ventricular double outlet combined with mild pulmonary stenosis and the body and pulmonary circulation are in a balanced state, palliative surgery should not be performed, waiting for the growth of infants to perform separate surgery or Fontan surgery. Preoperative preparation 1, the application of prostaglandin E1: on the first day after birth, severe cyanosis, the application of prostaglandin E1, open the arterial catheter, increase the blood flow of the lungs and the condition is in a stable state, waiting for the implementation of body-pulmonary shunt. Patients with aortic and aortic arch obstruction should also use prostaglandin E1 to allow blood flow to run forward through the catheter to improve systemic blood flow. 2. Correct metabolic acidosis, restore normal acid-base balance and liver and kidney function. 3. For cases of obstructed pulmonary venous return, emergency surgery is performed after mechanically assisted breathing and rescue. 4, fully oxygen, so that the systemic circulation and pulmonary circulation resistance are in equilibrium, and there is an adaptive systemic blood flow to supply the heart, brain and abdominal organs. However, in cases of combined aortic and aortic arch obstruction, oxygen is forbidden to prevent lung blood flow and severe pulmonary congestion. Surgical procedure 1. Modified subclavian artery and pulmonary artery shunt, pulmonary artery contraction and bidirectional cavopulmonary shunt. See "Fallo Quadruple Syndrome", "Rap Septal Defect" and "Tricuspid Atresia" for details. 2, direct ventricular septal defect expansion surgery This procedure is suitable for the left ventricle double portal with right residual left ventricle and ventricular and aortic connection inconsistent with aortic stenosis, heart ventricular ventricle less than half of the aortic root diameter below. The operation was performed under deep hypothermia (16-18 °C) continuous circulation of cardiopulmonary bypass or short-term stop circulation, and coronary artery perfusion of cold blood cardioplegia was used to protect the myocardium. A midline incision in the chest. The longitudinal incision of the ventricle through the double inlet of the ventricle is wedge-shaped from the ventricular septal defect to the apical interventricular septum, so that the defect size is equal to the aortic opening, and the patch is used to widen the outflow tract. 3, Damus-Kaye-Stansel anastomosis This operation is suitable for left left ventricle double entrance left residual ventricle and ventricular and aortic connection inconsistent with aortic stenosis. The basic method of cardiopulmonary bypass and myocardial protection are the same as the expansion of direct ventricular septal defect. The pulmonary artery was transected under the bifurcation, and the distal end was sutured with a 5-0 or 6-0 polypropylene double-layer, and the medial side of the proximal pulmonary artery was longitudinally incised. Close to the pulmonary incision, select the appropriate site to remove part of the ascending aorta, and then coincide with the longitudinal incision of the pulmonary artery, taking care not to twist the blood vessels and deform the aortic valve. A cap-shaped expanded polytetrafluoroethylene patch was used to cover the gap and repair of the aortic and pulmonary anastomosis. In the neonates, the modified subclavian artery and pulmonary artery shunt were added, and the bidirectional cavopulmonary shunt was added to the infants 4 to 6 months after birth. 4, modified Damus-Kaye-Stansel anastomosis This operation can be performed under deep hypothermia or low flow perfusion, the aorta is blocked at the proximal end of the innominate artery, and cold blood cardioplegia is perfused through the aortic root. The pulmonary trunk was transected proximal to the right pulmonary artery opening and the distal end was repaired and closed with a pericardium. Close to the innominate artery, the longitudinal incision of the ascending aorta was performed until the plane of the pulmonary artery trunk was transected. The vertical longitudinal incision made a transverse incision of the ascending aorta in the plane of the transection of the pulmonary trunk to form a self-aortic tissue piece. The posterior wall of the proximal pulmonary artery was anastomosed to the transverse incision edge of the aorta. The anterior incision was repaired with a triangular pulmonary artery patch, which was continuously sutured with a 7-0 polypropylene thread. Finally, the right subclavian artery and the pulmonary artery are connected by a diameter of 3.5 mm to 4.0 mm. 5, Norwood anastomosis This procedure is suitable for neonates and infants with left ventricle double entrance combined with ascending aorta and aortic arch hypoplasia. The deep myocardium was stopped and the cold blood cardioplegia was interrupted by coronary artery perfusion to protect the myocardium. Since the systemic blood flow depends on the right-to-left shunt, the arterial PCO2 must be maintained at 40-50 mmHg before the extracorporeal circulation, avoiding the excessive decrease of pulmonary vascular resistance and the reduction of systemic forward blood flow and pulmonary congestion. In the mid-thoracic incision, the arterial perfusion tube and the right atrium cannula were inserted at the proximal end of the pulmonary artery, and the bilateral pulmonary arteries were separated and covered with thick lines. After the flow, tighten the bilateral pulmonary artery band. When the temperature of the nasopharyngeal drops to 16-18 ° C, the head artery is blocked and the circulation is stopped. In the case of bilateral left ventricle with a right aortic transposition, the pulmonary artery is transected in the proximal pulmonary artery at the right pulmonary artery opening. Do not injure the pulmonary valve, and repair and close the distal end with a pericardium, and ligature the patent ductus arteriosus. The arterial catheter was severed on the aortic side and extended 6 to 7 mm distally. From the incision, the inside of the ascending aorta was extended to 5 mm above the aortic valve, and the same aorta was used to widen to 8 to 10 mm, and the suture was continuously sutured with a 7-0 polypropylene thread. The enlarged ascending aorta is anastomosed to the proximal end of the pulmonary artery. The fossa ovalis is removed through the right atrial incision to prevent heart block. At the same time, the modified subclavian artery shunt was performed in the newborn, and the bidirectional cavopulmonary bypass was performed in the infants 4 to 6 months after birth. 6, improved Norwood anastomosis This procedure is suitable for the left ventricle double entrance with left left residual right ventricle and ventricular and aortic inconsistent neonatal and small infants. Use deep cryogenic and stop cycling methods. A mid-thoracic incision was made to traverse the pulmonary trunk in the proximal part of the right pulmonary artery opening, and the distal opening was repaired and closed with a pericardial or homogenous pulmonary artery. The ascending aorta is traversed in the same plane, blocking the cephalic artery. The arterial catheter was ligated and severed at the distal end. It extends from the arterial catheter incision to the distal side of the descending aorta 1.0 cm and extends to the original transverse transection incision to the medial curvature of the aorta. According to the width of the ascending aorta, the 6-0 polypropylene suture was used to suture the pulmonary trunk and the proximal end of the ascending aorta was sutured 2 to 4 mm. The same pulmonary artery was used to enlarge the ascending aorta and aortic arch, and the enlarged distal aorta was anastomosed to the proximal end of the proximal end of the aorta and pulmonary trunk. Both were continuous with a 6-0 or 7-0 polypropylene thread. Stitching. Finally, the right subclavian artery and pulmonary artery were connected in a neonate or infant with a 3.5-5.0 mm expanded polytetrafluoroethylene tube. complication 1. Low cardiac output syndrome In patients with low cardiac output syndrome after 24 to 48 hours after Damus-Kaye-Stansel and Norwood anastomosis, tachycardia, hypotension, oliguria and metabolic acidosis often occur. Apply enhanced myocardial contraction strength medications and mechanically assisted breathing. Reasons for timely examination of low cardiac output: 1 myocardial inhibition caused by the decline of the entire ventricular discharge; 2 increased ratio of pulmonary circulation to systemic circulation (normal heart pump operation and abnormal blood flow distribution); 3 severe atrioventricular valve insufficiency. Once the cause is identified, it should be handled in a timely manner. 2, cyanosis after cyanosis may be caused by low cardiac output syndrome, anemia, pulmonary edema, pleural effusion, pneumothorax and pulmonary blood flow reduction. After diagnosis, chest X-ray and echocardiography, the treatment is based on the cause of cyanosis. 3, pulmonary vascular resistance after pulmonary congestion decreased, pulmonary blood flow more than systemic blood flow, although arterial oxygen saturation increased to 90%, but the systemic blood flow is insufficient, can produce renal insufficiency and can not leave the ventilator. The presence or absence of aortic arch blockage should be sought because more blood can be shunted to the pulmonary circulation due to blockage at its distal end. The aortic arch obstruction should be removed after surgery.