No more “defects” in the heart – treatment of complex precocious heart disease
Complex congenital heart disease is an important cause of death and disability in infants and children in China. Unlike simple congenital heart disease, complex congenital heart disease has a low natural survival rate and is difficult to treat, posing a more serious challenge to cardiac surgeons, but most complex congenital heart disease is still curable if reasonable surgical techniques and methods are used. In this expert interview, Sohu Health is honored to invite a famous cardiac surgeon, Professor Wu Qingyu, President of the First Affiliated Hospital of Tsinghua University and Director of the Heart Center, to explain complex congenital heart disease.
Moderator: Professor Wu, hello, welcome, first of all, please say hello to our netizens.
Professor: Hello, host, and good morning to all of you.
Moderator: We all know that there are 150,000 to 200,000 newborns with precocious heart disease in China every year, what is the proportion of complex precocious heart disease?
Professor: this proportion now there is no particular exact figures, we estimate that it may be about one-third of it.
Moderator: That is to say, the proportion of relatively high.
Professor: Yes.
Moderator: What are the types of complex precardiac disease?
Professor: There are many types of complex precocious heart disease, the most common one in children is tetralogy of Fallot. But the most common in newborns is complete transposition of the great arteries, and these are serious complex precardiac diseases.
Common complex precordial diseases
Complex precardiac disease tetralogy of Fallot is the most common
Professor: When it comes to complex precordial disease, the most common one is tetralogy of Fallot. In normal people, there are four chambers in the heart, and the atria and ventricles are relatively intact, while in tetralogy of Fallot, there is a large defect in the ventricular septum, and at the same time, the aorta growing in the left ventricle is displaced to the right – the aorta rides across, and where the pulmonary artery joins the right ventricle, the right ventricular outflow tract reaches the main pulmonary artery valve, and later on, each branch of the pulmonary artery becomes narrowed, and the blood flow is poor. This stenosis may cause an increase in right ventricular resistance, leading to myocardial hypertrophy and often combined with lesions such as arteriovenous insufficiency, combined with abnormalities in the development of the vena cava and superior vena cava, many abnormalities may occur simultaneously, but the most common is tetralogy of Fallot.
The most common and most effective method is radical surgery. That is, the defective part is replaced, and the stenosis can be resolved by unblocking the outflow tract, resolving the valve stenosis, widening the pulmonary artery reconstruction, and so on, using appropriate techniques to resolve the stenosis according to the situation. The main pulmonary artery of the right heart is widened and unblocked or not, and many ways to solve it. If normal, some patients can become basketball players, and this type of surgery has a history of more than 40 years by now, and there are records of patients who have lived more than 30 years after surgery.
Complete transposition of the great arteries is the most serious complex preconditioning
Professor: The other most serious precordial disease is complete transposition of the great arteries, and it is important for everyone to know what complete transposition of the great arteries is. The normal aorta emanates from the left ventricle, and the blood is transported to the whole body through the major branches of the aorta, which is the normal arterial system, after the blood containing oxygen in the lungs. The human venous system, oxygenated blood to the whole body through the tissue metabolism, and finally oxygen is used, some metabolic products in the tissue through the veins back to the right heart, and finally from the pulmonary artery to the lungs for oxygen and become arterial blood, the venous and arterial system combined into a normal circulatory system.
If the aorta is transposed, the aorta and coronary arteries are reversed, the blood flow of the whole body goes to the right heart, and all the metabolized hypoxic venous blood flow may finally go to the whole body. Then the well oxygenated blood flow from the lungs goes through the left atrium, through the left ventricle, and finally back to the lungs, and these two circulations are basically separated.
But how do these sick children survive? Originally, the two vessels, the ventricles, which should be separated from each other, may have a traffic port; that is, the aorto-pulmonary artery, which should be separated from each other, may have a duct that is open and has been kept connected, such as having an arterial ductus arteriosus, an atrial septal defect (traffic between the two atria), in order to maintain the survival of these children. So once the ductus arteriosus is closed off, the child may die, and more than 80% of infants will die within one year of age.
How can these children be treated? These ducts can be completely cut off, sutured, the defective atria and ventricles repaired, and then the two vessels are transferred back to their original places. In this process of transfer, because there is no oxygenated venous blood flow in the aorta, the blood flow that pours into the whole body is venous blood flow, the aorta is shifted and the coronary vessels have to be shifted with it, and the new aorta must be repositioned to find a suitable place in the aorta A hole is dug in the wall to re-graft the opening of the two smaller vessels to the newly created aorta. The transposition of the aorta must usually be operated on within two weeks of birth, and failure to do so is dangerous.
The most effective treatment for complex precordial disease is surgical cure
Moderator: Is surgery the only treatment for complex precordial disease?
Professor: Yes, this is the case all over the world, and only surgical treatment can be considered.
Moderator: Radical surgical treatment for complex precardiac disease is very effective.
Professor Wu Qingyu: But there is a relationship between the surgeon’s surgical technique and the severity of the patient’s condition. But there are some patients with the same disease may not be able to do radical treatment, such as different periods, have to wait for a little older to do. Some patients with poorly developed pulmonary arteries need to have a reduction surgery first, and then have a radical surgery when they have grown up and grown well and have all the conditions.
The treatment of complex precordial disease requires multiple surgeries, sometimes not necessarily the earlier the better
The host: You just mentioned that complex precocious heart disease sometimes requires treatment right after birth, some are treated at three months, and some at six months.
Professor: Children should be treated earlier to reduce the burden on the family and society if they are cured. But from the patient’s condition itself, this is not the case, like I said complete transposition of the great arteries, if not given treatment, pulmonary hypertension, pulmonary vascular, lung will produce lesions, later even if the recovery of heart surgery will not be good, in this case to operate as early as possible.
In the same way, if the pulmonary artery is not well developed, including pulmonary stenosis, these children need to have a pulmonary valve and pulmonary artery implanted because of the connection between the right ventricle and the lung, but so far these implanted tubes are not particularly suitable, and some tubes have a service life of more than 10 years at most, and must be replaced again. In order to avoid multiple surgeries, this kind of child should be operated a little later if possible. Because the earlier you do it, the more times you do it, the later you may operate a little less often. How to solve these pipeline problems is also an area that we are studying.
Parents should choose rationally the timing of surgery for complex precardiac disease
Moderator: For parents, this complex precocious heart disease surgery timing should be how rational choice?
Professor: for parents, complex precordial disease children can be seen at birth, because most of the performance is purple, in addition to some patients who are not very purple, the general doctor can be judged by auscultation, because there is a murmur. Some families do not care about this aspect at the beginning, but when the child is very sick and cannot work or run, then they go to the hospital. Sometimes they find us and seek help through various means, which we understand. The family wants to fight for a bo, is a gamble, in fact, they are misunderstood, this is not the problem of bo, is the result of what we know, surgery is not helpful to them, so in this case, we still can not consider surgery. This belongs to the first category, which should have been operated in time and discovered in time, and he delayed the operation because he did not pay enough attention to this aspect.
In the second category, heart disease is found at birth, but they don’t know how to treat it. Some patients may be born two days, three days, five days or six days before they need surgery. But these patients may need to wait, like poorly developed pulmonary arteries or narrow pulmonary outflow tracts, until the child is older and appropriate to consider surgery. Some children cannot survive without surgery, it is very powerful, we must find a way to do surgery for the patient, surgery can not do the root cause, can only be considered called bypass and palliative surgery, let the patient live first, let the lung and heart vascular conditions further development, the appropriate time to consider surgery.
The third case, like the aortic transposition I just mentioned, should be born and operated as soon as possible, so as soon as possible, palliative and conventional surgery are all possible, how to decide, let our parents first of all pay attention to this problem, the second to the hospital with conditions to check, find experienced doctors to help provide some advice, especially some very critical children, most like I just said to the big hospital directly hospitalized and then think about The way to solve.
Treatment of complex precordial disease in China has been part of the technology to catch up with foreign countries, but there is still a gap in the overall
Moderator: Complex precocious heart disease is a very difficult disease to treat. What is the overall level of treatment of complex precocious heart disease in China? What gaps do we still have compared to foreign countries?
Professor: In China, there are not many hospitals that can do complex precocious heart disease, no more than ten. There are not many doctors who can do complex precocious heart disease surgery, so overall we may have some gaps with developed countries. But this gap is not very big, there are aspects, some surgical efficacy should not be worse than foreign countries. But in terms of surgery itself, it is not just a matter of the surgeon doing the surgery well, it requires teamwork. Children with complex precardiac disease are fragile and delicate, and are prone to infections and respiratory complications, so how to give nutrition and medication is very precise and accurate. Before discharge from the hospital, the patient is under supervision, which requires a high level of overall teamwork, so in this regard, there is definitely a gap between the level of the team and foreign countries.
But a dozen years ago some complex precocious heart disease may be the whole country complex precocious heart disease can not be cured, unless to foreign countries for treatment, in the country may not be cured, or not wait for you to treat the patient has died. But now these large hospitals in China can do these operations, and the child can recover very well, which is a great progress.
We have many children who were operated on within 10 days of birth, and now they are all doing well. After the operation, the normal heart examination found that these children are just like normal children, and the examination of various departments can show that the aorta was transposed before, but now it has completely returned to normal.
Moderator: Yes. I would like to ask which specific hospitals in our country can do it?
Professor: The larger hospitals in Beijing and Shanghai can do it. Now, Tsinghua First Affiliated Hospital, Anzhen Hospital, Shanghai Children’s Medical Center, Nanjing Children’s Hospital and so on can perform surgery for complex precocious heart disease.
For children with complex precocious heart disease, neither parents nor doctors nor society should choose to give up.
Moderator: Many complex precocious heart disease surgery is risky, and even requires multiple surgical treatment, many parents are afraid of the risk of surgery, and give up treatment, is this not very appropriate?
Professor: This is a relatively complex issue, not only parents consider whether to cure the problem, the actual involves many aspects, is a social problem and the reality of some problems. I don’t want to say everyone understands, I just give an example, we operated on this child for 11 hours after birth, this child was actually six months pregnant in the fetus, is suffering from complete transposition of the aorta, but the family said this child must be, must be preserved. And at that time, they knew that this child would need to be operated, and they trusted me to operate on him. Finally, he came to our hospital and let the child be born, so this concept and trust in us is the guarantee of doing the surgery. If you can find a better hospital, doctors and nurses who can help you to turn an unhealthy child, or a dying child, into a normal person, I think it is a good thing to do. However, different families and parents may have different perceptions and considerations of these issues, but as a hospital, doctors and nurses, as long as the patient has a disease we must find a way to treat him first, the second is to strive for the best treatment results, to reduce the burden on patients and families or reduce the burden on society, which is the responsibility of our hospitals and doctors.
China’s tricuspid valve subluxation malformation treatment technology world leader
Moderator: We understand that you are very accomplished in the treatment of tricuspid valve subluxation malformation, and that the efficacy of surgery for tricuspid valve subluxation malformation in China is in the world’s leading position. What is the current success rate of the surgery?
Professor: Tricuspid valve subluxation is a congenital heart disease, also known as Ebstein malformation.
In a normal person, the right ventricle has three leaflets, and the leaflets themselves are connected to the subvalvular papillary muscles with tendons, and there is a device that connects the leaflets, the annulus, and the papillary muscles, just like a door, which are three components of the valve, like a parachute, and the parachute is intact.
The size and position of the tricuspid valve leaflets in patients with Ebstein’s malformation are not different from those in normal subjects. First of all, the three leaflets of the tricuspid valve are not normal, they grow bigger than they should, and some of them do not grow, or they grow very small. This is the first one, the size difference.
In patients with Ebstein malformation, the tricuspid valve grows in a different position than in normal people. Normal people grow to the level of the base of the annulus, but in these people it may grow at a different level, at least in most people, like the posterior septal leaflet is shifted down, which is the most common. The distance of the downward shift varies from one centimeter to two or three centimeters, or even to the apical part of the heart, which is not well developed, and the position of the downward shift and the enlargement of the annulus cause the right ventricular valve to fail to close and the blood to regurgitate.
Tricuspid valve subluxation itself can be combined with many conditions, such as preexcitation syndrome, ventricular hypoplasia, arteriovenous ductus arteriosus, and possibly transposition of the great vessels.
If left untreated, a subtricuspid valve deformity may become more and more severe, but in some patients it may not be visible after birth and may only be detected when the patient is very large.
The first step in surgery for a subtricuspid valve deformity is to address the valve, which may change if it does not grow properly. In the past, the main treatment for tricuspid inferior valve deformity was a plastic surgery approach. This disease has been done the most number of the earliest number of the overall or the United States of America, Minnesota, a hundred kilometers south of the city of Medical City, where they did the earliest. According to the traditional approach, is not the valve lobe subluxation? Give it a lift. The other way is to replace the valve, but what are the problems with replacing the valve?
The first problem: we have to replace the valves that are commonly used now, one is a mechanical valve, we have to give these patients a lifetime of anticoagulants so that the blood can not clot, once clotted, the valve leaflet is stuck. Once stuck in the lungs will soon be dangerous. The anticoagulant can not be stopped, the child is so small, at any time bump, may be a bleeding is not easy to stop, daily medication for life, almost often laboratory tests, can not leave the hospital, there may be a variety of bleeding or thrombosis risk.
Another problem is that the mechanical valve leaflet may have to be replaced again when something around it grows in.
Can there be a valve that doesn’t require anticoagulants? There is what we call a tissue valve, which is usually made of pericardium or other materials, and is commonly used today. But for children, these valves break down more quickly, usually in about ten years the valve must have failed, and rarely for longer. Consider that even if you start replacing them at age three or five, once every ten years or once every twenty years, and with the difficulty of each heart surgery, heart surgery will be more difficult than ever.
The third problem is that these children may be born very small, and some valves may not be the right size, and even if they can be put in, it will affect the function of the heart in terms of contraction, which is not normal.
The French also use a similar method to do this, but it is better than the American method.
So far, no doctor in the world has treated more patients with better results than I have in this procedure. How are we going to solve this problem? We do a lot of basic research, including animal experiments, and clinical improvements. For example, this valve place originally did not grow at all, you said there is no way we can make him have a valve leaflet? But if there is, can he grow on it? And so on many questions, we have done a lot of systematic and rigorous research in the past. For example, the autologous pericardium, which was used in many heart surgeries in the past, was found to be able to grow on, and we made the autologous pericardium into a leaflet and sewed it on the septum, which probably no one in the world has done experimental studies and found. The normal one has three leaflets, which should grow big enough and good enough to work, but now they are growing in the wrong position and growing in a mess, can these abnormalities be put together into a near normal leaflet, no one has such experience. The defective leaflets can be replaced with other materials, and there are also leaflets that grow abnormally on their own. So we found in the end during the clinical process that these problems should be achievable. This is the solution to the leaflet problem, what about these problems with the tendon papillae? What about these problems below? We were able to find ways to, for example, this muscle is very abnormal, it’s growing there itself is a redundant, abnormal bundle of muscle that needs to be removed and affects the blood flow. By standing it up and joining it to that leaflet, that solves the problem of the papillary muscle. Then the annulus is abnormally enlarged, we turn the annulus into normal size, these problems are solved, what about the atrium and valve, atrialized ventricle part? Whether in the United States or in France, their approach is to fold it, both horizontally and vertically, but the folding approach may often be due to the extent of some very large, the future does not grow well or will also leak blood. The method we use now is to cut off a large part of it and restore the normal shape of the entire ventricle.
Why do other experts not dare to do this? Because the blood vessels are very important and the coronary artery is passing through there, they dare not solve it. The way we think of it keeps these vessels in place and allows these heart muscles to overlap again and increase the contractile force of the heart. It is easy to understand that we are making a complete change from the ventricle itself, the annulus, the leaflets, and the tendons to the patient’s original material and foundation. Even if we cannot restore all patients to normal, a large proportion of them can become normal.
The biggest meeting of our specialty is the annual meeting in the United States, once a year, there may be more than 5,000 experts attending the meeting, of course there are not so many experts in congenital heart disease, but in this meeting, I gave a presentation in the congress in ’07, about the treatment of congenital heart disease. No one before me had given that lecture on the Chinese experience on how to treat congenital heart disease.
All these work, on the one hand, we help these patients, on the other hand, we let our colleagues all over the world know that we Chinese are not inferior to them in many aspects of treatment, especially in surgery for precocious heart disease.
Moderator: This aspect should be the absolute world leader.
Professor: Some aspects can be said, but not all, there are many aspects. The most important thing is to know what our shortcomings are, and we will try to solve them one by one.
Complex precordial disease after surgery should adhere to the medication, appropriate exercise, regular review
Moderator: Just now you also mentioned that children with complex precardiac disease still need careful care after treatment, parents have many questions, what are the precautions needed?
Professor: complex precordial disease after surgery heart healing process, early heart function is still poor, need some drugs, at least a year to eat, Ebstein malformation at least a year to six months of those drugs, so that it completely grows well, and recover well. In addition, after the operation can not be strenuous exercise, must wait for the complete growth of the case, if the process is not enough attention, the child is not well managed, too much exercise, may have an impact on the outcome of the operation. It is also important to go to the hospital regularly to see the doctor for a review. Many patients’ families ask if they can get vaccinations. There is no relationship between the vaccination of children after surgery. A part of patients can have a family and children after surgery. It is important to evaluate the child according to his or her surgery. It is also important to note that some families should be aware of the psychological changes of the child at different times after surgery, and should communicate and care more for the child, but should not be pampered.
Leading heart experts teach you to prevent heart disease
Moderator: Professor Wu, how do you think we should prevent precocious heart disease? How should you protect your heart in normal times?
Professor: Pre-heart disease prevention usually occurs in the first trimester of pregnancy, and the mother has to prevent it during the process. If for a normal person to get heart disease, it is an acquired heart disease, and these problems that come afterwards are the ones that need to be able to pay attention to. The most common disease is coronary artery disease, which is a familiar disease. According to the World Health Organization, this disease is the first cause of human death, and what are the complications that often occur with this disease? Because the coronary artery disease after myocardial infarction, valve problems, ventricular rupture may have, many comorbidities may occur, such as heart rate disorders, in this case, do not want to happen after the results. It is important to prevent atherosclerosis when you are young, and the fact that you can see atherosclerosis on the operating table in the youngest children at the age of 14 means that many people should start to prevent atherosclerosis from a young age. How to prevent it? Not to smoke is one of the aspects, appropriate active participation in sports, control diet, control blood pressure, control blood sugar, control blood lipids, reduce the psychological and various aspects of the burden, maintain a healthy state of mind, regular life. Probably the most important thing is to control weight, diet, blood sugar and blood lipids, and to quit smoking.
Introduction to the First Affiliated Hospital of Tsinghua University Heart Center
Moderator: We are nearing the end of the interview, please introduce the heart center of the First Affiliated Hospital of Tsinghua University.
Professor: As many of you may know, I have been working in Fu Wai for 28 years, and I have been the vice president there for 9 years, mainly in charge of medical and nursing care, and also as the director of cardiac surgery. We know how foreign doctors work and how foreign cardiology departments are organized and managed, because we often have some international exchanges and foreigners come to hospitals, including those who have studied in foreign hospitals. In comparison, we have a certain gap. This gap affected the development and academic progress of our hospital, so at that time I thought it was possible to build a good heart center. We wanted to organize the best backbone and form a team according to our purpose. The second one can drive the training of young people and influence some colleagues around us, so that we can do a good job together and let everyone recognize this matter. This is how the Heart Center of the First Affiliated Hospital of Tsinghua University was born.
We have a very good team in the heart center, with experts in all aspects, cardiac surgery, imaging, anesthesia, cardiology, nursing, and some other departments, including some backbone of our cardiac surgery department, the technology is very good. Now there are almost two hundred beds, and all of our doctors and nurses add up to almost two hundred people, so the scale is still relatively large.
Last year, we performed more than 3,000 surgeries in total. I came to work at this hospital on April 3, 2004, and we performed our first surgery on April 17. The number of patients we have solved so far is not very large, there are more than 3,000 patients, but the most important problem is that more than 1,900 of them cannot be treated by any hospital in the country, such as many complicated precordial diseases. Thanks to the trust these patients have placed in us, we will find ways to do things that are meaningful to patients and meaningful to society, which is our duty and our desire. We hope to improve what we may not have done well so that we can do better and better.
The time and place of consultation of specialists
Moderator: Thank you very much. Finally, please tell us about your consultation time and location.
Professor: Generally speaking, I only visit the hospital on Monday afternoons, mainly for consultations.
Moderator: Thank you very much for coming to us and explaining so much about complex precocious heart disease to all of us.