Congenital heart disease (congenital heart disease) is a class of common diseases that seriously endanger the health of children, with an incidence of 0.6% to 0.8%, and 150,000 to 200,000 new cases of congenital heart disease each year in China. In recent years, there has been great progress in the diagnosis and treatment of precardiac disease, and it is possible to make early and accurate diagnosis and surgical cure for various precardiac diseases. Currently, the treatment of common precardiac diseases including patent ductus arteriosus (PDA), atrial septal defect (ASD), ventricular septal defect (VSD) and pulmonary stenosis (PS) includes medical treatment, transcatheter intervention and surgical treatment; while the treatment of cyanotic precardiac disease includes surgical and medical-surgical mosaic treatment. The mode and timing of treatment are chosen according to the condition.
I. Internal treatment
1.General treatment
1.1 Nutritional supplementation Children with precocious heart disease often suffer from malnutrition and growth retardation, so it is important to pay attention to the ratio of protein, fat and carbohydrate, as well as vitamin and water supplementation, and if necessary, intravenous or nasal feeding is also necessary to supplement nutrition [1].
1.2 Prevention and treatment of infections Children with precardiac disease are prone to bronchitis and pneumonia, especially in left-to-right shunt precardiac disease, so special attention should be paid to the prevention and treatment of infections; children with precardiac disease are also prone to combined infective endocarditis, with ventricular septal defect, tetralogy of Fallot, patent ductus arteriosus, and aortic stenosis, often occurring before and after surgery; in recent years, mitral valve prolapse with regurgitation has been recognized as a cause of pediatric infective endocarditis as the underlying disease [1].
1.3 Regular follow-up Some precardiac diseases such as ASD, VSD, and PDA have a chance of spontaneous closure; therefore, regular follow-up can detect the results in a timely manner; in addition, regular follow-up can also assess the prognosis of precardiac disease and determine the timing and modality of treatment.
2.Drug treatment
2.1 Closed PDA The incidence of PDA in preterm infants is 25%, of which 80% can be closed spontaneously. Indomethacin can be applied in combination with infection or heart failure, which is usually effective 24-48 hours after the drug is administered, but with greater side effects [1].
2.2 Open PDA The main application is prostaglandin E, which has the effect of dilating the arterial duct, increasing pulmonary blood and improving hypoxemia, and is suitable for neonates with severe cyanotic preconditioning who rely on open arterial ducts to maintain life [1].
2.3 Treatment of complications Precardiac disease can cause more complications, which should be treated promptly. If heart failure, it is treated with digitalis, vasodilators and diuretics; if pulmonary hypertension, it is treated with pulmonary vasodilators, sodium hypophysis and oxygen and nitric oxide inhalation; if hypoxic episodes, it is treated with oxygen, drugs to relieve spasm of the right ventricular outflow tract, correction of acidosis and anemia, etc.
Transcatheter interventional treatment
1.Transcatheter valvuloplasty
1.1 Percutaneous balloon pulmonary valvuloplasty (PBPV) is performed by delivering a specially designed balloon catheter to the valve stenosis and dilating the balloon to relieve the stenosis. The indications are typical PS; partial dysplastic pulmonary stenosis; post-surgical or post-PBPV restenosis. Trans-pulmonary valve pressure step difference ΔP ≥ 35 mmHg. age and weight are not limited, severe PS should be treated in the neonatal period or infancy; for PS in small infants under 1 year of age, the selected balloon size should be 90-100% of the pulmonary valve annulus; for PS patients over 1 year of age, the selected balloon size can be 120-140% of the pulmonary valve annulus []2.
1.2 Percutaneous balloon aortic valvuloplasty (PBAV) Indications are non-valvular dysplastic aortic stenosis with thin and mobile valves that have a transvalvular pressure step difference ΔP ≥ 50 mm Hg. The diameter of the selected balloon catheter should be ≤ diameter of the aortic annulus, with a balloon/annulus ratio of 0.9 to 1.0 [2].
2, Laser/RF perforation
It is mainly used in neonatal cases of pulmonary valve atresia/intact septum, and it is performed by laser catheter or radiofrequency current catheter to excite through the atretic pulmonary valve followed by balloon valvuloplasty.
3.Transcatheter angioplasty
A specially designed stent device is delivered to the stenosis site under the guidance of a balloon catheter, and the stent is opened and released by inflation of the balloon. It is mainly used for aortic stenosis, pulmonary artery branch stenosis, left and right outflow tract stenosis after complicated precordial disease, and vena cava pulmonary vein stenosis.
4.Transcatheter occlusion
4.1 PDA occlusion The spring ring or mushroom umbrella occluder is sent to the location of the arterial catheter through the cardiac catheter to close the arterial catheter and achieve the purpose of occlusion treatment. The indications are typical PDA, age >6 months, weight >5kg; residual shunt after PDA surgery. 2mm PDA, choose mushroom umbrella blocker. when PDA without pulmonary hypertension, choose blocker larger than PDA 2~3mm; when PDA combined with pulmonary hypertension, choose blocker larger than PDA 4~6mm, when PDA diameter >8mm, choose blocker larger than PDA 6~8mm [ 3].
4.2 ASD occlusion The mushroom umbrella blocker is opened on the left and right side of the defect opening through the cardiac catheterization technique, and the defect is closed under echocardiographic surveillance. The indications are typical secondary foramen ASD, age >3 years, weight >10 kg; distance between the edge of the defect and the superior and inferior vena cava, right superior pulmonary vein and coronary sinus ≥5 mm, distance from the atrioventricular valve ≥7 mm; pediatric patients with maximum septal extension diameter ≥14 mm diameter of the defect opening; those with unclosed foramen ovale, stroke, or previous combined cerebral embolism, or family history of stroke. Blocker selection: 30 mm defect, blocker type +6~8 mm.
4.3 VSD occlusion The femoral artery-VSD-femoral vein track is established by cardiac catheterization technique, and the mushroom umbrella blocker is opened on the left and right sides of the defect and the defect is closed under echocardiographic surveillance. The indications are typical myocardial and perimembranous VSDs, age >3 years, weight >10 kg; pediatric defect orifice diameter.