ventricular septal defect repair

Ventricular septal defect can coexist with other congenital heart malformations, such as large vessel transposition, tetralogy of Fallot, complete atrioventricular common tract, etc. Simple ventricular septal defect can be divided into four categories according to the anatomical part of the defect: 1. Or (pulmonary artery) dry defect. 2. High or membrane defect. 3. Defects in the atrioventricular or septal flaps. 4. Muscle defect ventricular septal defect often combined with aortic valve prolapse caused by insufficiency or right ventricular outflow tract stenosis, and sometimes with arterial ductus arteriosus, atrial septal defect, pulmonary stenosis and other malformations. Treatment of diseases: ventricular septal defect ventricular septal defect Indication 1. The ventricular septal defect may be automatically closed before 10 to 12 years old. Some people do not advocate premature surgery, but there is almost no death due to the operation of such patients. If surgery is not performed, not only will parents and patients have heart murmurs. There is a mental burden or difficulty in entering school, and there is a risk of bacterial endocarditis or heart valve inflammation, so it has recently been included in surgical indications. 2. There is a heart enlargement and a large number of left to right shunts. 3. Infants with large ventricular dysfunction, pulmonary hypertension, left heart failure, repeated lung infection, pulmonary hypertension and growth dysplasia should be operated early. 4. Patients with ventricular septal aortic regurgitation should be operated promptly. 5. Patients with pulmonary stenosis or outflow tract stenosis are mostly large. Patients with obvious stenosis may have a right-to-left shunt and should be operated together. 6. Pulmonary hypertension, pulmonary artery pressure / aortic pressure <0.75 can be operated, but the postoperative high pressure can not be completely eliminated. Contraindications Pulmonary arterial pressure / aortic pressure > 0.90 is contraindicated surgery. Pulmonary arterial pressure / aortic pressure of 0.75 ~ 0.90 patients with poor long-term postoperative results. Preoperative preparation 1. Eliminate all infected lesions. 2. Correct malnutrition, anemia, and liver, kidney, and other organ dysfunction. 3. Correct heart failure or put the patient in the best possible condition. 4. Stop the digitalis and diuretics 48 hours before surgery. 5. Use an ordinary diet 1 week before surgery to adjust the electrolyte balance. If the patient takes long-term diuretics, the oral potassium chloride should be increased in the first week before surgery to overcome the deficiency of potassium in the body. 6. Start antibiotics with antibiotics on the 3rd day before surgery. Give a dose of antibiotics when you use the medicine before surgery. 7. In severe cases, glucose, insulin and potassium chloride solution (gik) were intravenously administered 1 week before surgery to protect the myocardium. 8. Psychotherapy should be performed on patients before surgery to eliminate concerns and enhance cooperation between doctors and patients. Let the patient understand the various situations that may occur during the operation to facilitate the patient's active cooperation. Surgical procedure 1. Reveal the heart and establish extracorporeal circulation. 2. Heart incision (1) through the right ventricular incision: commonly used. The tremor site was examined outside the heart, parallel to the coronary vessels, and the right ventricular myocardium was incised obliquely. Care should be taken to protect the coronary vessels from damage. (2) through the right atrial incision: from the right atrium through the tricuspid valve for lower position ventricular defect repair, or high membrane defect, with left ventricular right atrial leakage, revealed quite satisfactory, and the heart burden is lighter than the right ventricular incision More, especially for those with pulmonary hypertension. (3) Trans-pulmonary incision: repair of the dry type defect through the pulmonary valve. (4) through the left ventricular incision: muscle defects, especially multiple, sieve-like defects, right ventricular incision revealed poor left ventricular incision, clearly revealed defects. 3. Reveal the defect area. Pull the happy wall incision gently with the pull wire and the hook, and carefully search for the defect. If covered by chordae or papillary muscles, it can be gently retracted around the thick thread. If the defect is not found, ask the anesthesiologist to expand the lungs, let the blood in the lungs enter the left ventricle, and pour into the right ventricle from the defect to find the defect. 4. Repair the defect Patch repair: If the defect is large, the diameter is about 1.5cm, the flow rate from left to right is more, and the pulmonary artery pressure is higher. It should be repaired with polyester sheet. Take the repair of the membrane defect as an example: (1) Lower edge after intermittent suture stitching: After revealing all defects, use 3-0 or 4-0 double-headed polyester thread and gasket to make 3~4 needles along the edge direction at about 0.5cm from the edge of the lower lower edge. Sewing, each needle is 3 to 4 mm wide. Do not penetrate the entire interval of the septum, and the depth should be half of the thickness of the interventricular septum to avoid damage to the conduction beam. The distance between each type of intermittent needles should be small to avoid gaps and incomplete repair. One of the sputum sutures, in addition to passing through the ventricular septal muscle, should be placed close to the annulus through the root of the tricuspid valve so that no gap is left between the ventricular septum and the tricuspid valve. (2) Sewing polyester sheet: The broken edge type is passed through the lower edge of the polyester sheet which is slightly larger than the defect, and tightened and tied firmly (because the polyester thread is slippery, the knot should be played 6). Except for the top and bottom stitches, remove the excess thread. 5. Continuous suture uses a long line to suture the remaining edges of the defect with the polyester sheet continuously, and the upper and lower thread ends are ligated with the remaining intermittent sputum thread. The lung should be dilated or irrigated to the left ventricle before ligation. The tricuspid valve should be placed at the root and close to the annulus; the suture of the uppermost needle should be passed through and tightened with the supracondylar to avoid gaps in the middle. Direct suture: If the defect is small, there is a complete white fiber ring around, and the pulmonary artery pressure is not high, which can be directly sutured. (1) Intermittent suture suture: According to the size of the defect, firstly make 1~2 needles with a padded suture, each needle penetrates the fiber edge and is not ligated. (2) 8-shaped or continuous suture: also 8-shaped or continuous suture in the annulus. Generally, 1 or 2 8-shaped sutures can include the full length of the defect. After suturing, the lungs are expanded or the left room is irrigated and ligated. (3) Ligation of the suture stitch: Finally, the suture suture is ligated. 6. Check whether the repair is thorough: If left atrial or left ventricular drainage has been performed during the establishment of extracorporeal circulation, saline can be injected through the drainage tube to observe whether there is residual defect in the repaired area and overflow of saline. If there is no drainage tube, please anesthetist to expand the lungs. If there is still salt water or blood rushing out of the defect, it indicates that there is residual defect, that is, the sputum or 8-shaped suture should be added to the hemorrhage site until there is no more bleeding. 7. Suture myocardial incision: If atrial or pulmonary incision is made, the incision can be closed by continuous augmentation with continuous acupuncture and acupuncture, such as a ventricular incision, which can also be used with continuous suture plus continuous double suture. Simple sutures close the incision. In case of blood leakage, use a dry gauze to gently press to stop bleeding. If there is more blood leakage and the pressure can not stop bleeding, it can be added as a simple or squat or 8-shaped suture. 8. Re-jump, remove the tube, and suture the chest wall incision.