Right-sided open-heart surgery for congenital heart disease Objective To explore the indications and technical keys for the application of right-sided open-heart extracorporeal circulation surgery for congenital heart disease. Methods The clinical data of 678 patients with congenital heart disease treated by right-sided open-heart extracorporeal circulation surgery were retrospectively analyzed. Results: 512 cases of ventricular septal defect repair, 113 cases of atrial septal defect repair, 32 cases of radical treatment of tetralogy of Fallot, 11 cases of partial endocardial cushion defect correction, 5 cases of triple atrial heart correction and 5 cases of other malformations; there was no death in this group, 28 cases of postoperative complications occurred, including 6 cases of open heart hemostasis, 1 case of late pericardial effusion via pericardial drainage, 1 case of III degree atrioventricular block with permanent One case of permanent pacemaker was installed for third degree AV block, 19 cases of residual shunt <2 mm, and one case of secondary tracheal intubation. Conclusion Right-sided open-heart correction of congenital heart disease is effective, less traumatic and faster recovery. With the increasing safety of congenital heart disease (CHD) surgery, such as Atrial Septal Defect (ASD), Ventricular Septal Defect (VSD), Tetralogy of Fallots (TOF) with well-developed pulmonary arteries, etc. The safety is high, and how to reduce the surgical injury and the aesthetic and concealed incision is gradually gaining the attention of patients and surgeons. We used a small incision on the right lateral thorax to complete the corrective surgery of precordial disease under extracorporeal circulation, and achieved satisfactory results, as reported below. 1, general data From January to September 2011, 678 patients, 363 males and 315 females, aged 2 months to 40 years old, average 36.6 months, 210 patients <1 year old, body mass 3.8 to 69 kg, average 13.5 kg, 288 patients <10 kg, were treated by right-sided open-heart surgery. The number of right-sided open-heart surgery accounted for 51.7% of the total number of simultaneous surgery for preconditioning and 56.9% of the total number of extracorporeal circulation surgery. The types of precardiac disease are shown in Table 1. The other 5 cases were 2 cases of right ventricular double outlet, 1 case each of left coronary artery right atrial fistula, aortic left ventricular access and mitral stenosis. 2. Methods Tracheal intubation with intravenous compound anesthesia was performed with the child lying on the left side, with the left axillary pad 8 to 10 cm high and the right arm abducted and fixed to the head frame. A 6- to 8-cm-long curved incision was made between the intersection of the right posterior axillary line and the third intercostal space and the intersection of the anterior axillary line and the sixth intercostal space, and the thoracic cavity was entered at the fourth intercostal space through the inferior border of the pectoralis major muscle, taking care to protect the long thoracic nerve and internal mammary artery. The pericardium is incised longitudinally along the front 2 cm of the phrenic nerve, superiorly to the aorta with the pericardium reflexed, and inferiorly to the inferior vena cava with the pericardium reflexed. The ascending aorta and the superior and inferior vena cava were cannulated and extracorporeal circulation was established. The correction of intracardiac malformation was performed under regular extracorporeal circulation. There were no deaths in this group. 5 infants were operated through the third intercostal approach and 2 adults through the fifth intercostal approach, and all of them completed the operation successfully. There were 28 cases of postoperative complications. There were 6 cases of open-heart hemostasis due to postoperative bleeding, 1 case of late pericardial effusion via pericardial drainage, 1 case of III degree AV block with permanent pacemaker, 19 cases of residual shunt <2 mm, and 1 case of secondary postoperative tracheal intubation. There was no incisional infection, phrenic nerve palsy, residual pressure difference in the right ventricular outflow tract, or low cardiac output syndrome. The residual shunt disappeared in 17 cases and decreased in 2 cases during the postoperative follow-up period of 3 to 10 months. 3 Discussion With the increasing maturity of cardiac surgery technology and the continuous development of related departments such as anesthesia and extracorporeal circulation, the safety of conventional surgery has been improving high, and the postoperative survival age and activity level are not significantly different from those of healthy people, therefore, how to reduce the trauma of surgery on the body and mind is getting more and more attention. The traditional median incision surgery is more traumatic in terms of sternal splitting, higher probability of leaving a chicken chest, and the obvious postoperative incision scar can have a psychological impact. In contrast, the small right-sided incision is less invasive, has a hidden scar, is aesthetically pleasing, keeps the chest intact and stable, and has less psychological impact on the child. Several centers in China have experience in completing surgical treatment of congenital heart disease using the right-sided open-chest approach. Good exposure and the smallest possible trauma are the basis for deciding the surgical approach. In children with a small chest cavity, a heart close to the chest wall, elastic ribs, and weak muscles in the lateral chest wall, some scholars believe that the best age is 2 to 5 years old with good surgical exposure via this route and a body mass of 15 kg, which is the most appropriate operation. In our data, 30.9% were <1 year old and 42.5% had a body mass <10 kg, indicating that the indications for surgery are gradually expanding as surgical techniques continue to mature. However, patients with complex malformations with unclear preoperative diagnosis, right-sided heart, severe adhesions to the right pleura, combined severe pulmonary hypertension, and extremely poor pulmonary vascular development in TOF are still contraindications to right-sided open heart surgery. Adopting the correct operation method is the guarantee of surgical results. In right-sided open-heart surgery, the ascending aorta is poorly exposed due to its high position, therefore, successful aortic cannulation is the key to this pathway surgery. In this group of cases, all aortic cannulae with special connectors presenting 1200 were used, which are characterized by suitable angle, clear direction, easy fixation, and not easy detachment. Incorrect selection of the intercostal space for entering the chest can increase the difficulty of aortic cannulation, with older children prone to enter from the fifth intercostal space and younger children prone to enter from the third intercostal space. Conventional experience [8], in case of incorrect intercostal positioning, intermittently adjacent to the front of the rib, extends the incision forward and downward. Although there were isolated intercostal positioning errors in this group, including especially in the presence of adult surgery via the fifth intercostal entry, which posed a great challenge to the aortic cannulation technique. However, due to the operator's extensive experience with right-sided open-chest surgical techniques, he was able to complete the surgery successfully with conventional intubation methods without incision extension and other treatments. In this group, although there was an intercostal positioning error, so that the adult surgery entered the chest through the fifth intercostal space, it was still possible to complete the surgery with the conventional intubation method. The management of the special problems encountered during the operation is also one of the keys to the success or failure of the operation. First of all, the preoperative diagnosis of a child who is to undergo right-sided open-heart surgery should be clear about the presence of aortic arch narrowing, PLSVC ectopic drainage, left upper pulmonary vein ectopic drainage, PDA, and left pulmonary artery stenosis. Combined PDA, PLSVC, PS, SAS and sub-stem VSD repair, repair of myocardial VSD, and TOF radical treatment are not contraindications to surgery, but are technically demanding, and the operator should be skilled in simple precordial surgery with a right-sided incision and have the skills to handle special problems with a median incision before starting right-sided open-heart surgery. Due to the special nature of the surgical position and the adjustment of the intraoperative operating table tilt, attention should be paid to the timely adjustment of the relative height of the arterial and venous pressure transducers during surgery to avoid making wrong judgments about the unstable intraoperative circulation. To avoid damage to pulmonary function during right-sided open-heart surgery, attention should be paid to the following: keep the right phrenic nerve more than 1 cm away from the right side of the pericardium when cutting the pericardium to avoid postoperative diaphragmatic paralysis; place wet gauze between the right edge of the pericardium and the traction line on the right chest wall after opening the pericardium to separate the right lung from the operative field and reduce mechanical injury; temporarily open the ventilatory tube of the anesthesia machine after opening the pericardium to remove some of the gas in the right lung, or appropriately reduce the tidal volume ; venting the pulmonary artery before and after opening the circulation. Pulmonary complications were less common in this group of cases. The incisional approach used in this study is different from the previous anterolateral dissection of the chest, which is located in the anterior axillary line and posterior axillary line area, and enters the chest from the lower border of the pectoralis major muscle gap, away from the breast and anterior chest muscle tissue, avoiding damage to the relevant important blood vessels and nerves, so that their development is not affected and the cosmetic effect is good . And the incision location is hidden, small trauma, fast recovery, especially the future psychological impact on the child is small. On the basis of proficiency in conventional surgical techniques and special surgical skills, it is a better choice for the treatment of precordial heart disease.