Surgical treatment of complete endocardial cushion defects in infants and children Abstract: Objective To explore the surgical methods and complications prevention and treatment of endocardial cushion defects in infants and children. Methods Thirty-five children with complete endocardial cushion defects under the age of 3 years were treated surgically, and the combined malformations were also dealt with. Results Five cases died in the early postoperative period, with a mortality rate of 14.2 G. The causes of death: two cases were severe hypocardia that could not be removed from the extracorporeal circulation, two cases of hypocardia combined with pulmonary infection and multi-organ failure, and one case abandoned treatment. Conclusion: Children with complete endocardial cushion defects have early pulmonary vascular disease and should be treated with surgery as early as possible. The key to successful surgery is the effect of mitral valvuloplasty to avoid atrioventricular block and to prevent the occurrence of postoperative pulmonary hypertension crisis. Keywords:complete endocardial cushion defect, infants and young children, surgical treatment, complete endocardial cushion defect is a complex cardiac malformation, with early clinical symptoms such as cardiac failure and recurrent respiratory infections, and poor natural prognosis, which requires surgical treatment in infancy and early childhood; 35 cases of complete endocardial cushion defects in infants and young children under the age of 3 years have been admitted to our department from June 2002 to May 2012, and the surgical methods and efficacy of these cases are summarized below. Data and methods: There were 35 cases in this group, including 19 males and 16 females; age 0.2-3 years, mean (0.7±0.5) years, 25 cases under 1 year; weight 3.5-12kg, mean (4±1.2) kg, 33 cases under 10kg. All children had different degrees of malnutrition, 21 cases of recurrent epiglottitis and pneumonia (2 of them were on ventilators, and the pneumonia could not be controlled and required emergency surgery), and 10 cases of cardiac insufficiency; systolic murmurs of grade 2/VI or above were audible in the 2nd to 4th intercostal space of the left sternal margin, and systolic murmurs of grade 2-3/VI could be audible in the apical region; the pulmonary artery was hyperpituosity in 28 cases, and the pulmonary artery was attenuated in 2 cases; electrocardiograms showed that Atrial enlargement in 32 cases, right ventricular hypertrophy in 18 cases, left ventricular hypertrophy in 8 cases, biventricular hypertrophy in 7 cases, first-degree atrioventricular block in 6 cases, and incomplete right bundle-branch block in 15 cases; Chest radiographs showed varying degrees of pulmonary congestion, cardiothoracic ratio of 0.52-0.76, average (0.62±0.2), echocardiography suggesting endocardial cushion defects, and varying degrees of regurgitation. Rastelli staging: 20 cases of type A, 11 cases of type B, and 4 cases of type C. The combined single atrium was found in 7 cases. There were 7 cases of combined single atrium, 6 cases of ductus arteriosus, 2 cases of pulmonary valve stenosis, 8 cases of secondary foramen ovale defect, 5 cases of left upper chamber remnant (including 2 cases of inflow into the left atrium), 2 cases of right ventricular double outlet, and 4 cases of trisomy 21. There were 23 cases of moderate or higher pulmonary hypertension. All children were performed under moderate hypothermic extracorporeal cardiac arrest, with aortic block time of 65 to 113 min, mean (110±25) min, and diversion time of 102 to 215 min, mean (145±45) min. Intraoperative ventricular septal defects were seen to be an average of 10 mm×25 mm, and interatrial septal defects were seen to be an average of 20 mm×31 mm; surgery was performed through the right atrial incision, and a There were 15 cases of single-piece repair, 11 cases of double-piece repair, 9 cases of modified single-piece repair, 31 cases of mitral cleft repair, 8 cases of mitral annuloplasty, 7 cases of tricuspid cleft repair, and 12 cases of tricuspid annuloplasty. The coronary sinus was isolated into the right atrium in 25 cases and into the left atrium in 10 cases. Results: intraoperative esophageal ultrasonography was performed in 10 cases, and there was no moderate or above mitral regurgitation requiring re-blocking repair; postoperative ventilator-assisted time ranged from 13 to 345h, with an average of (103±67)h, ICU supervision ranged from 2 to 17d, with an average of (6±4)d. Postoperative cardiac and vasodilator treatments were routinely given, and prostaglandin E1 was used in 5 cases, and adrenaline was used in 17 cases. Postoperative death 5 cases, mortality rate of 14.2G, 2 cases of postoperative low cardiac output can not be removed from the extracorporeal circulation died. 2 cases due to low cardiac output, respiratory failure died. 1 case of combined trisomy 21 4 days after surgery, pulmonary hypertension crisis, endotracheal intubation, ventilator-assisted respiration for 10 days, the family to give up the treatment, the rest of the children were recovered from the hospital, the postoperative follow-up to be 2 months to 5 years, echocardiography suggests that the mitral valve Echocardiography showed that there were 10 cases of mild mitral valve insufficiency, 4 cases of mild-moderate insufficiency and 1 case of severe insufficiency, 7 cases of mild-moderate tricuspid valve insufficiency and 4 cases of moderate insufficiency. DISCUSSION: Children with complete endocardial cushion defects have severe hemodynamic disorders, early pulmonary capillary lesions, recurrent respiratory infections, cardiac failure and other clinical symptoms at an early stage, and should be treated with surgery as soon as possible because of the poor effect of medical control and high mortality rate. The surgical methods for complete endocardial cushion defects include the traditional single-piece and double-piece methods, and the modified single-piece method advocated in recent years. The modified single-piece method is to sew the atrioventricular flap directly downward on the septal ridge to close the septal portion of the atrioventricular channel, which can be attempted for the children with shallow septal defects, and it simplifies the surgical operation in comparison with the previous two surgical methods; our department has tried using the modified single-piece method for the children with ventricular septal defects of less than After 2008, our department tried to use the modified single-piece method for children with septal defects smaller than 10 mm, and the aortic block time was significantly shortened, and there was no residual shunt or outflow tract stenosis in the postoperative follow-up. Postoperative conduction block is most commonly caused by local tissue trauma or mechanical injury to the conduction system, and may also be caused by hypothermia, hypoxia and acidosis; intraoperative myocardial protection can be strengthened by using HTK myocardial protection fluid; surgical operation should be as gentle as possible; once conduction block occurs, isoproterenol can be used in the early stage, and at the same time, hormones and cardiac trophic fluid can be used, and the duration of the extracorporeal circulation can be prolonged appropriately, and sufficient oxygen can be given, rewarmed, and if this is ineffective, temporary pacing can be placed. If this is not effective, a temporary pacemaker should be placed; in this group, one case of postoperative atrioventricular block of the third degree, a temporary pacemaker was used for one week to restore the autonomic rhythm, and then it was removed two weeks later. The common causes of postoperative valve regurgitation are poor valve development or tearing of the valve after suturing; the valve tissues of infants and young children are tender, and the valve area is small, so the operation is difficult and risky, especially the molding effect of the mitral valve has a direct impact on the postoperative cardiac function of the children; the intraoperative pulling of the valve is as gentle as possible, and the suture should be made by using the autogenous pericardial sheet or the pericardial sheet of bovine as the spacer, to prevent the leaflet from tearing; different molding methods can be selected according to different conditions of the leaflets; after molding the leaflets, the spacers should be used to avoid tearing; according to different conditions of the leaflets, different molding methods can be selected. According to the different conditions of the valve leaflets, different molding methods should be selected, and after molding, repeated water or transesophageal ultrasound should be used to observe the regurgitation of the valve, and if unsatisfactory, the valve should be transferred to another machine as soon as possible; postoperative mitral regurgitation should be strengthened with cardiac tonicity, diuresis, and vasodilatation, and should be followed by ultrasound and closely observed, and if necessary, a second operation should be carried out. Postoperative blood pressure should be controlled to prevent high blood pressure caused by valve suture tear aggravate valve regurgitation; early postoperative sedation to avoid unnecessary stimulation, appropriate prolongation of ventilator-assisted time, appropriate hyperventilation is conducive to pulmonary vasodilatation, selection of sodium nitroprusside and prostaglandins and other pulmonary vasodilator, to reduce the occurrence of pulmonary hypertension crisis.