Overview
Congenital Heart Disease CHD (CHD) is the most common cardiovascular disease in children. Foreign epidemiological surveys show that there are 45 cases of atrial septal defect (ASD), 15 cases of ventricular septal defect (VSD), 15 cases of patent ductus arteriosus (PDA), 10 cases of aortic constriction (CoA), 45 cases of other, and 500 cases of patent foramen ovale (PFO) per 3 million population. ) in 500 cases. According to the statistics of our health department, there are 4 million patients with precardiac disease in China, most of them are children, and the number of newborn children with precardiac disease is as high as 150,000 to 200,000 every year, and the incidence is on the rise.
The vast majority of precardiac diseases can be completely cured, and with the improvement of medical technology and the development of interventional techniques, more and more precardiac diseases can be treated by interventional methods. At present, China performs about 60,000 cases of surgery for precardiac disease and 20,000 cases of interventional surgery for precardiac disease every year, with more than 600 hospitals and 120 hospitals carrying out the procedure independently. The overall success rate is 92.3~99.6%, complications 1.97%~4.45%, and mortality rate ≤0.11%. Therefore, clarifying the typing and diagnosis of congenital heart disease, mastering the best timing of surgery for various congenital heart diseases, and choosing the appropriate treatment are the knowledge that cardiovascular and pediatricians should master and deserve attention.
Congenital heart disease is divided into three types according to hemodynamics: left-to-right shunt type, right-to-left shunt type and outlet obstruction type.
The best timing of surgery and treatment for left-to-right shunt type congenital heart disease The best timing of surgery for right-to-right shunt type congenital heart disease: VSD 2 to 3 years old, PDA 3 months to 5 years old, ASD 3 to 5 years old, partial atrioventricular septal defect > 5 years old, complete atrioventricular septal defect 2 to 3 months old, recurrent congestive heart failure with more than 2 malformations and PH should be operated within 6 months after birth.
1, arteriovenous ductus arteriosus The incidence accounts for 15% to 21% of precardiac disease, women are two times more than men, and the incidence of premature infants has increased significantly. For all types of PDA with weight ≥ 3 kg and internal diameter 1-15 mm, interventional treatment can be used; especially for adults with significant calcification of the vessel wall aged > 30 years, open-heart surgery is prone to complications such as bleeding, residual leakage and aneurysm, and interventional treatment should be the first choice of treatment.
2, atrial septal defect accounted for 10% of children’s precocious heart disease, accounting for 21.7% to 24.6% of adult precocious heart disease, natural closure within one year after birth accounted for 55%. The ratio of female to male is 2 to 3:1, women are mostly found during pregnancy, and <50% of those who survive to 40-50 years old without surgery, with an annual mortality rate of about 6%. Without combined malformation and pulmonary hypertension, age >3 years, interventional treatment is feasible in about 80% of secondary foramen type ASDs, and surgical treatment is required in venous sinus type (superior or inferior cavity type), primary foramen type, and those with huge defect with bad edges.
3.Ventricular septal defect (VSD) The incidence of VSD accounts for 20%-30% of precordial diseases, and there are about 30-50 thousand children born every year
VSD is divided into membrane (including simple membrane, tricuspid septal subvalvular type, perivalvular type), funnel (including inferior stem type, intracrural type), myocardial and myocardial VSDs and residual leak after VSD repair can be considered for interventional treatment, while other types or patients with large defects require surgical treatment. Patients with other types or large defects require surgical treatment.
The optimal timing of surgery and treatment for right-to-left shunt type of precordial disease
1. The incidence of complete transposition of the great arteries (TGA) is 0.2‰ to 0.3‰, with a male to female ratio of 2-4:1. If left untreated, the mortality rate reaches 51.6% within 1 month and 89% within 1 year. For TGA with different deformities, the timing of surgery is also different.
(1) Patients with intact ventricular septum should undergo surgical treatment within 2 weeks after birth;
(2) In children with VSD, surgery should be performed within 3 months after birth (within 2m or 1m);
(3) Children with VSD combined with narrow left ventricular outflow tract (without PS, DORV, total pulmonary vein ectopic drainage) should undergo surgical treatment within 3 to 4 months (including within 2m or 1m);
(4) Those with PAH combined with main pulmonary collateral (MACAS) should undergo surgical treatment in 4-6m after birth.
(2) Corrective transposition of the great arteries Children with VSD without PS should undergo surgical treatment within 6 months after birth; children with PS, DORV, with or without VSD should undergo surgical treatment at the age of 2 to 3 years after birth.
3.Farrow quadruplex with hypoxic attack should be surgically corrected in infancy; children with mild symptoms without hypoxic attack can undergo surgical treatment at the age of 2-3 years;
4.Farrow’s triad should be surgically treated as soon as it is diagnosed.
5.Pulmonary atresia with intact ventricular septum accounts for 0.71%~3.1% of precordial disease, if not treated, 85% die within six months, 52% mortality within one year after surgery, radiofrequency perforation and balloon dilation should be performed as early as possible.
6.Right ventricular double outlet
(1) Taussig-Bing should be treated surgically in 3-6 months after birth;
(2) With PAH, surgery should be performed 6-12 months after birth;
(3) Surgery with PS should be performed at 4-5 months;
7.Permanent arterial trunk
(1) In the absence of pulmonary stenosis, surgery should be performed 2 to 3 months after birth;
(2) Those with pulmonary stenosis or pulmonary vascular resistance <80 kPa.s/(L.m2) should undergo surgical treatment within 1 year of age;
8.Complete pulmonary venous ectopic drainage
(1)Those with obstruction or heart failure should be treated surgically within 1 year of age;
(2) without obstruction or heart failure, surgical treatment should be performed within 5 years of age;
(3) Exit obstruction type congenital heart disease
1.Pulmonary valve stenosis (PS)
(1) Percutaneous pulmonary valve stenosis balloon dilatation (PBPV) should be performed as soon as severe PS is diagnosed;
(2) PBPV or endocardial correction is usually performed at 2 to 5 years of age;
(3) Indications for PBPV.
(1) PS alone, PVPG >30 mmHg;
(2) PS combined with other cardiac malformations that can be treated interventionally;
(3) Transitional treatment of TOF;
④Post-surgical or post-PBPV restenosis;
2.Aortic stenosis (AS)
(1) Percutaneous balloon aortic valve stenosis (PBAV) or surgical treatment should be considered for those with one of the following
(1) Infantile congestive heart failure;
(ii) Angina pectoris or syncope;
③Electrocardiographic left ventricular hypertrophy with strain;
④Transvalvular pressure difference >60 mmHg;
⑤valve orifice effective area index <0.8cm2;
(2) Indications for percutaneous aortic valve stenosis balloon dilatation.
①Good valve activity, no significant valve dysplasia;
(2) Transvalvular pressure difference >50 mmHg, without or with mild aortic regurgitation;
As of 2009, 71 fetal PBAVs were performed at Boston Children’s Hospital in the United States, 56 of which were technically successful, and 50 of which were fetal survivors. Of the successful fetuses, 20 (36%) achieved biventricular circulation, and only 1 (7%) of the 15 failed procedures achieved biventricular circulation. Although technically feasible, in-depth studies are needed to select fetuses suitable for interventional treatment.
3.Aortic constriction
(1) Simple constriction can be treated surgically at the age of 4 to 8 years;
(2) Infants and children with severe symptoms should be treated with immediate surgery;
The aortic constriction stent trial (COAST), in which 12 hospitals participated to evaluate the efficacy and safety of bare metal stents and overmolded stents (NuMED) in the United States, enrolled 25 patients to date, 13 with primary CoA and 12 with postoperative restenosis, with a mean age of 15 years and a mean body weight of 67 kg. no serious complications related to the intervention, and the pressure difference at the constriction decreased from 29 mmHg preoperatively to 1 mmHg postoperatively. The short-term efficacy and safety data are encouraging, but the long-term efficacy and safety remain to be tested.
For precordial disease, the diagnosis should be clarified as early as possible and appropriate treatment should be taken to achieve early detection and early treatment, so as to avoid missing the best time for surgery and resulting in the inability of the child to undergo treatment.