OBJECTIVE: To summarize the results of radical surgery for tetralogy of Fallot (TOF) performed via small right lateral dissection in infants and children aged 0-3 years, and to discuss the experience of supervision of radical surgery for TOF performed via small right lateral dissection. METHODS: We retrospectively analyzed 142 cases of TOF radical surgery completed from January to December 2011 at the age of 0-3 years, 47 cases of TOF radical surgery performed via right lateral mini-incisional dissection, and 95 cases of TOF radical surgery performed via median dissection. flow, left atrial pressure, positive inotropic drug score, time on ventilator, length of stay in the monitoring room and postoperative hospital stay. RESULTS: Forty-seven cases of TOF radical surgery were performed via small right lateral incisional dissection, including 15 cases (accounting for 32％) with transannular patching. The mean age of this group was 13.34±6.41m (5-34m), mean weight was 9.58±1.17kg (6-14kg), preoperative oxygen saturation was 87.57％ ±9.02 (69-99％), McGoon ratio was 2.06±0.48 (1.11-3.36), intraoperative extracorporeal circulation time 95.95±26.31min (40-170min), aortic block time 67.95±17.57min (30-117min), chest drainage 140.7±130.0ml (10-850ml) on the postoperative day, left atrial pressure 9.19±2.12mmHg (3-14mmHg), positive inotropic drug score 8.57±3.97 (2-19), 30.9±31.33h (4-165h) of ventilator use, and 2.86±1.94d (0-9d) of monitoring unit stay. Postoperatively, there were 2 cases of secondary open-chest exploration due to excessive chest drainage. Residual shunt was found in 2 cases (2 mm). Compared with a matched group of 95 cases with orthotopic dissection for radical treatment of TOF during the same period, there was no difference in preoperative clinical data, no difference in intraoperative extracorporeal circulation time and aortic block time, and the postoperative stay in the guardianship unit was significantly shorter in the right lateral small incision dissection group than in the orthotopic dissection group. The remaining items were not different from those of the median dissection group. CONCLUSION: On the basis of proficiency in surgical techniques and strict selection of surgical indications, right lateral small-incision dissection can be applied in radical surgery for TOF. With the proficiency of the right-sided incision technique, experienced surgeons have gradually applied it in more complex corrective surgery for congenital heart disease. The following is a retrospective summary of the experience of perioperative monitoring of infants and children with tetralogy of Fallot performed via small right lateral incisional dissection from January to December 2011 at our center. Data and methods: 1. Clinical data: A total of 142 radical TOF surgeries in infants and children aged 0-3 years were summarized in our center from January to December 2011. 47 radical TOF surgeries were completed via small right lateral dissection, accounting for 33.1％ of the number of radical TOF surgeries in the same period and 4.8％ of the number of small right lateral dissection surgeries in the same period. In the same period, 95 cases of TOF radical surgery were performed by conventional median sternotomy, and the detailed clinical data of the two groups are shown in (Table 1). (1) The right lateral small-incision dissection group was stricter than the median dissection group in the selection of indications for radical TOF surgery. Children with unclear preoperative diagnosis, children with severe adhesions in the right pleura on X-ray, children with very poor pulmonary vascular development or children with significant stenosis at the beginning of the left pulmonary artery could not choose the right lateral small-incision open-chest method. Before surgery, echocardiography and X-ray are routinely performed, and if necessary, spiral CT or cardiovascular angiography is performed to clarify the diagnosis and combined malformations. To understand the development of the pulmonary artery and left ventricle and to clarify the coronary artery and the presence of coarse body pulmonary collateral branches. (2) Right lateral small incision dissection technique: The child is placed in the left lateral position with the left axillary pad 8-10 cm high and the right arm abducted and fixed in the head frame. The thorax was entered between the right anterior axillary line and the posterior axillary line, through the inferior border of the pectoralis major muscle, at the 4th intercostal space, paying attention to the protection of the long thoracic nerve and internal mammary artery. The pericardium is incised longitudinally along the phrenic nerve for 2 cm, up to the aorta and the pericardium, and down to the inferior vena cava and the pericardium. The correction of the intracardiac malformation is a routine TOF radical surgery procedure under extracorporeal circulation. Thoracic drainage tube: In this group of children, one drain was placed in the right side of the chest and one in the pericardium, leading from the intercostal space below the incision, with the chest drain below the axillary midline and the pericardial drain 1-2 cm above the chest drain. Intraoperative and postoperative clinical data are detailed in Table 2 below. 3. Postoperative monitoring points: (1) Respiratory management: This group all used SERVO-i infant and child ventilator from MAQUET with SIMV (PRVC) breathing mode. Parameters: Respiratory rate 25-35 breaths/min, tidal volume 6-8 ml/kg, positive end-expiratory pressure (PEEP) 2-8 cmH2O, detect peak airway pressure 15-25 cmH2O, pressure support 10 cmH2O. ensure PaO2≥70 mmHg, PaCO2≤40 mmHg. gradually increase PEEP to 6-8 cmH2O if pulmonary blood distribution is asymmetric or there is more intrapulmonary exudate. to 6-8 cmH2O, while strengthening diuresis to maintain negative balance of the volume. The PEEP should be reduced to 0-2 cmH2O before ventilating, and the child should be safely detoxified without powdered sputum and stable circulation. If the child is still in respiratory distress such as trigeminal sign, nasal flap, shallow and rapid breathing, PaO2 decrease, or powder sputum appears and continues to worsen, non-invasive positive end-expiratory pressure ventilation (N-CPAP) can be applied after detubation. PEEP was set at 4-6 cmH2O, ventilation flow (Flow) at 8-14 L/min, and inhalation oxygen concentration (FiO2) was adjusted according to PaO2. There was no secondary tracheal intubation in this group of children, and no serious intrapulmonary exudate was found. (2) Circulatory management: Monitor left atrial pressure and right atrial pressure, use dobutamine, epinephrine, milrinone and other vasoactive drugs appropriately to maintain stable vital signs; increased RAP with decreased blood pressure indicates right heart insufficiency, deepen sedation, increase ventilator conditions, maintain hyperventilation (PaCO2 at 35 mmHg), inhale NO or use milrinone to reduce pulmonary resistance, and control the rate of fluid rehydration. Increased left atrial pressure with decreased blood pressure suggests left heart insufficiency, and the dose of vasoactive drugs should be increased. In the early postoperative period, the blood volume should be actively replenished, plasma and albumin can be used to improve the colloid osmotic pressure, and ensure that the hematocrit reaches 120 g/L, and control the intake of 70-90 ml/kg/d on each postoperative day. control the body temperature at 36.5-37.5℃, maintain the metabolic balance, actively correct the acidosis, ensure the terminal warmth of the child, lactate, venous oxygen saturation is basically normal, urine volume ≥2 ml/ kg/h, or the above indicators are in an improved state. (3) Other treatment: appropriate sedation can reduce the afterload of the right ventricle, the children in this group used continuous intravenous pumping of fentanyl 1-2μg/kg/h, reduced to 0.2-0.3μg/kg/h when trying to stop the ventilator, can be successfully off the machine, the whole group did not find apnea after off the machine. Nutritional support: children with mild disease were fed 4h after extubation. Ventilator use greater than 24h seriously ill children apply gastric tube regular nasal milk, and with part of the intravenous nutrition, preparation of pediatric compound amino acids 100ml, 50％ glucose 60ml, hydralvata 10ml, Andamax 6ml, 0.9％ saline 20ml, a total of 196ml. depending on body weight and fluid control of the day 5-10ml /h continuous pumping, application of early detection of blood glucose, insulin can be applied to regulate blood glucose in the normal range. Ventilator use > 72h or gastrointestinal milk absorption poor children apply fat milk 0.5-1g/kg/d onwards, maintain 24h continuous pumping, while monitoring liver and kidney function, blood lipids. Infection prevention and control: Routinely apply second-generation cephalosporin antibiotics 100mg/kg/d for 4-7 days to prevent infection. Blood routine and C-reactive protein were monitored daily. Infected children were first upgraded with broad-spectrum antibiotics, while sputum, blood and catheter tip culture were performed, and sensitive antibiotics were selected according to drug sensitivity. 4. Study methods and statistical treatment Retrospective analysis was performed to compare the preoperative oxygen saturation, hematocrit, McGoon’s ratio, intraoperative extracorporeal circulation time and aortic block time, and postoperative chest drainage, ventilator use time on the same day, monitoring room stay, postoperative hospital stay, orthostatic inotropic drug score and left atrial pressure. All experimental data were expressed as mean ± standard deviation. Two-sample mean t-test was used for comparison between groups. P< 0.05 was considered as a difference. RESULTS: There were no surgical deaths in the right lateral mini-incisional dissection group, and no differences were seen in preoperative age, weight, hematocrit, oxygen saturation, and McGoon ratio, intraoperative extracorporeal circulation time and aortic block time compared with the matched median dissection group for radical TOF in the same period, and postoperative time of stay in the guardianship unit was significantly shorter in the right lateral mini-incisional dissection group than in the median dissection group, and positive muscle strength drug score and left The atrial pressure was significantly lower than that of the orthotomy group. The remaining items were not different from those of the orthotomy group. Major postoperative complications: 2 cases of open-chest hemostasis, 2 cases of residual shunt less than 2 mm, and 5 cases of transient bloody sputum in the right lateral small-incision dissection group. There was no secondary tracheal intubation, incisional infection, phrenic nerve palsy, pneumothorax, pulmonary atelectasis, cardiac arrhythmia, and low cardiac output syndrome after surgery. In the median dissection group, there was one case of open chest hemostasis, three cases of residual shunts (one of which was a myocardial residual shunt), three cases of rapid arrhythmia, one case of secondary intubation, one case of sternal fracture and two cases of death. Discussion: As the safety of cardiac surgery continues to improve, postoperative aesthetics is gradually gaining attention. As early as 1996, there were case reports of extracorporeal cardiac surgery completed by small right lateral incision dissection in Fu Wai Hospital. Today, with the increasing maturity of cardiac surgery and related departments, small right lateral incisions to complete extracorporeal cardiac surgery are increasingly accepted by doctors and families of children. In recent years, this surgical technique has been gradually expanded from simple pre-cardiac correction to the correction of low weight infants and relatively complex pre-cardiac disease. The right lateral mini-incisional dissection for radical surgery of TOF requires strict operator requirements, in addition to experience in median dissection for TOF and extensive experience in right-sided open-chest correction of simple precordial disease. In addition, the selection of indications is particularly important. The preoperative diagnosis and combined malformations should be clearly defined. Therefore, a good grasp of the indications for right-sided open-heart surgery, improved surgical proficiency and the ability to complete the surgery successfully can help reduce the occurrence of complications. Postoperative monitoring experience: ① bleeding: two cases in this group were found to have excessive chest drainage for the second open-chest exploration, and no significant bleeding was found, and the drainage was significantly reduced after clearing the fluid and blood clot. The treatment paid attention to maintaining circulatory stability, actively replenishing lost blood volume, and applying hemostatic drugs at the same time. For the complication of postoperative thoracic drainage in children, attention should be paid during the operation. If it is difficult to stop bleeding under the beating heart, sutures can be added again under extracorporeal circulation to stop bleeding. It is often more difficult to stop bleeding, especially when a wide patch is applied to a homogeneous vessel piece. Maintenance of respiratory function: In older children, some authors have reported that right-sided anterior open-heart surgery is more detrimental to pulmonary function, mainly due to disruption of negative intrathoracic pressure by right-sided open-heart surgery, compression or pulling of lung tissue, secretions from the right lung into the left side, and wound pain affecting coughing and sputum removal. Our incision is more lateral; the age group of the child is significantly younger; after opening the chest, gauze is placed between the right edge of the incised pericardium and the traction line on the right chest wall to separate the right lung from the operative field and reduce mechanical injury; the anesthesia machine ventilation tube is temporarily opened to exclude some of the gas in the right lung or to reduce the tidal volume appropriately; the pulmonary artery venting is emphasized before and after opening the circulation, thus pulmonary complications are rare. In some children, transient blood sputum appears in the early postoperative period due to the compression of the right side of the right lung after right-sided chest opening. The effect of compression is especially obvious in children of low age and weight. Intraoperative attention should be paid to controlling the rate of volume replenishment after the heart resumes beating. Postoperatively, attention should be paid to the peak airway pressure detected by the ventilator, and it is advisable to set the respiratory parameters with a small tidal volume of 6-8 ml/kg. After appropriate extension of the ventilator assist time, addition of positive end-breath pressure, and use of hemostatic drugs, the treatment is usually significantly reduced or even disappeared within 8-12 hours after surgery, and the total ventilator use time is about 30 hours. After extubation, the treatment can be continued with non-invasive positive end-expiratory pressure ventilation. There was no significant impact on the child’s outcome. Since the incision of the right lateral mini-incision dissection was smaller than that of the median dissection, the damage to the child was less and the postoperative recovery was relatively fast. There was no difference in ventilator use time between the two groups, but the mean ventilator use time in the right lateral mini-incision dissection group was slightly shorter than that in the median dissection group. Due to the special nature of the right chest wall incision, the children should pay attention to appropriately reduce the stimulation of the right chest wall to reduce pain during postoperative pulmonary care, especially during back patting and suctioning. ③Key points of postoperative circulatory system management: maintain effective blood volume, appropriate arterial blood pressure, central venous pressure, and left atrial pressure. Maintain the appropriate heart rate. Maintain electrolyte, acid-base, and fluid balance. Appropriate ambient temperature, maintain body temperature 36-37℃, avoid hyperthermia. Reasonable mechanical ventilation to minimize intrathoracic pressure and not to obstruct venous return. The postoperative positive muscle strength drug score and postoperative left atrial pressure in this group were significantly lower than those in the orthotomy group, and the duration of stay in the monitoring room was significantly shorter than that in the orthotomy group because the selection of indications in this group was particularly strict, and some children with uneven pulmonary vascular development and more lateral branches of the body lung were not enrolled, so the postoperative recovery process was smoother than that in the orthotomy group. There were no postoperative complications such as arrhythmia and low cardiac output syndrome in this group. In conclusion, based on strict selection of surgical indications, right lateral small-incision dissection for radical surgery of TOF is feasible, and the postoperative recovery process was smooth with no serious complications or surgical death.