Part I: Twenty questions on congenital heart disease
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1. What is the function of the heart ?
To sustain life and carry out daily activities, humans must have a supply of oxygen. Oxygen and other nutrients are carried by the blood to various tissues and organs. The heart works like a pump, pumping blood to all parts of the body. Blood carries oxygen and nutrients to the body’s cells, and collects the waste products produced by these cells. The circulating blood also maintains a constant body temperature. The heart is actually two parallel power systems, one pumping blood to the lungs (via the pulmonary artery) and the other pumping blood to all parts of the body (via the aorta). The pulmonary artery, which has a lower pressure than the aorta, carries the “dirty blood” (oxygen-deficient blood) from the various parts of the body to the lungs to “wash” (breathe) it into fresh blood (oxygenated blood), while the aorta, which has a higher pressure, carries fresh blood to the various parts of the body.
2. What is congenital heart disease?
Congenital heart disease is a cardiovascular malformation caused by abnormal or impaired cardiovascular development during fetal life and failure to degenerate the tissues that should degenerate after birth. Congenital”, as the name suggests, is an inborn condition; that is, a heart condition that is present at birth. The fetal heart develops early in the mother’s pregnancy (within 2 months); therefore, cardiac anomalies can occur early in the embryo. Unfortunately, modern medicine has not yet been able to detect cardiac anomalies in the early embryonic period.
3. Causes of precordial disease.
The main causes of precordial disease can be divided into two categories: genetic and environmental. According to relevant data, simple genetics accounted for 8%, simple environment accounted for 2%, genetic and environmental interactions accounted for 90%. If there are patients with precardiac disease in the family, the mother has respiratory infections in early pregnancy, diabetes during pregnancy, alcohol consumption, radiation exposure, improper medication during pregnancy, etc., should pay great attention and vigilance. Because the children of such mothers have the possibility of heart disease
4. What is the incidence of congenital heart disease?
The incidence of congenital cardiovascular disease is reported to be 8.1 per 1,000 in the United States and about 7 per 1,000 in China. This means that for every 1000 babies born, 7 have different types of congenital cardiovascular disease. About a quarter of people with congenital heart disease will have other physical abnormalities in combination.
5. What are the effects of congenital heart disease on the child?
Children with congenital heart disease may experience shortness of breath during exercise or breastfeeding, so they may not eat enough, and their growth may be slower than normal. Some of them may have purple coloring all over the body or lips; others may have very little energy and are easily tired.
6. Is congenital heart disease hereditary?
Occasionally, members of the same family may also have congenital heart disease. However, the chance of having a child with congenital heart disease in the next child is about 2 to 4 percent (three to five times); similarly, the chance of having a child with congenital heart disease in a parent with congenital heart disease is 10 percent. If both parents have congenital heart disease, or if the parents are consanguineous, the risk of congenital heart disease in their children is even higher.
7. What are the types of congenital heart disease?
Congenital heart disease is generally divided into three major categories. (1) Left-right shunt type: (no cyanosis type) with ventricular defect, atrial defect and arteriovenous ductus arteriosus as the most common, with clinical manifestations such as frequent colds, fever, pneumonia, sweating, wasting and weight loss. (2) Right→left shunt type: (also called cyanotic type) with tetralogy of Fallot and large-vessel misalignment is the most common. The clinical manifestations are purple lips, face, fingers and toes after birth or 6 months after birth, easy sweating, wheezing, but not many colds, and after learning to walk, they like to squat, i.e. walk a bit and squat a bit. (3) No shunt type, with pulmonary artery stenosis, aortic constriction is common, clinical boys are more common, not many colds, seemingly normal, grow to 7-8 years old after the emergence of walking fast or upstairs shortness of breath or purple lips and other phenomena.
8. What are the most common congenital heart diseases?
After birth, the most common congenital cardiovascular malformations are interventricular defect, atrial septal defect and patent ductus arteriosus, followed by simple pulmonary stenosis, tetralogy of Fallot, aortic stenosis and aortic constriction, in addition to aortic transposition, etc. The above eight malformations account for more than 85% of all congenital cardiovascular lesions.
9. Home care for children with congenital heart disease
The following aspects should be noted.
Try to keep the child quiet, avoid excessive crying and ensure sufficient sleep. The older children should have a regular life, a combination of movement and stillness, neither running around outside (running and jumping and strenuous exercise are strictly prohibited), nor do they need to lie in bed all day, and sleep must be guaranteed at night to reduce the burden on the heart.
Children with cardiac insufficiency tend to sweat more, so they need to keep their skin clean, bathe regularly in summer, rub themselves with hot towels in winter (pay attention to keeping warm), and change their clothes and pants regularly. Feed more water to ensure sufficient hydration.
The child should eat less and more meals, ensure adequate intake of protein and vitamins, and give as diverse and easily digestible a diet as possible.
Keep the stool smooth, if the stool is dry and difficult to defecate, excessive force will increase the abdominal pressure, increasing the burden on the heart, and may even have serious consequences.
Keep the air circulating in the room, and avoid staying in crowded public places as much as possible to reduce the chance of respiratory tract infection. Add and remove clothes in time with the warm weather and pay close attention to the prevention of colds.
Regular follow-up visits to the cardiology clinic of the hospital and strict compliance with medical prescriptions, especially for cardiac and diuretic drugs, due to their pharmacological properties, the dosage must be absolutely controlled and taken on time and according to the course of treatment to ensure their efficacy. Before each dose of cardiac drugs, pulse count must be measured, if the heart rate is too slow, should immediately stop taking, to prevent the occurrence of toxic effects of drugs, endangering the life of the child.
10. Can I take vaccination?
Of course! All general vaccinations, including whooping cough, should be given on time. The vaccination can only be postponed if the child is sick, congenital. Children with heart disease must have a good resistance to fight all kinds of infections, so they need vaccinations even more!
11. Is there any risk for children with heart disease from common childhood illnesses?
Minor illnesses such as the common cold will not cause too much trouble, but more serious illnesses must be given special attention by a physician.
12. Is there any problem with the other organs of a child with congenital heart disease?
No! Unless he has multiple organ abnormalities.
13. Should the child know that he has a heart disease ?
No need for secrecy. Secrecy will only make the child suspect that there is something wrong with him and will affect his mental development.
Should we tell the child what he is doing in the hospital ?
Yes. It is best to let the child know the purpose of the visit, whether it is for a test, an operation, or just an outpatient follow-up.
15. Those congenital heart diseases that require surgery and those that can be cured naturally without surgery are often manifested as palpitations, shortness of breath, fatigue, cough, hemoptysis, and even fainting and right heart failure when the congenital heart disease is older. Once the diagnosis is clear, we should strive for early surgery to achieve the purpose of radical cure, if not treated, the pulmonary artery pressure and right heart pressure will keep increasing, the right-to-left shunt will appear in the heart, the lips of the mouth will be blue, clinically known as cyanosis, it is late, then the surgery is lost. At this time, the chance of surgery is lost and most of them cannot have any treatment. Therefore, early diagnosis and timely treatment is the key to a healthy life for children. For some mild congenital heart diseases, such as arteriovenous ductus arteriosus has the possibility of automatic closure within three months; nearly half of the atrial diaphragm defects will close automatically within one year of age; more periventricular interventricular diaphragm defects can be closed by themselves before 2 years of age, so surgery can be suspended and observed clinically, but if the defect persists, it will have to be repaired surgically. As for tetralogy of Fallot, complete transposition of the great arteries and other complex congenital heart diseases, only surgical interventions can cure them.
16. Those congenital heart diseases that must be treated surgically in infancy
In general, those that do not correct completely or partially in infancy will evolve into irreversible pulmonary vascular obstructive disease, i.e., should be corrected in infancy to prevent the continuation of pulmonary hypertension. Even if cardiac surgery is successful, right heart failure may result due to high pulmonary blood pressure, and a heart-lung transplant may be necessary to save life. These diseases include complete transposition of the great arteries, complete pulmonary vein ectopic drainage, severe narrowing or disruption of the aorta combined with ventricular diaphragm defect or aortic window, hypoplastic left heart syndrome, etc. Other conditions such as tetralogy of Fallot, right heart hypoplasia, severe pulmonary stenosis or even atresia also often require surgical correction in infancy. In cases of heart failure due to left-to-right shunt, the need for surgery in infancy is determined by the failure.
17. What tests should be done before open heart surgery?
Electrocardiogram, chest X-ray, routine blood and liver function tests and cardiac ultrasound are all mandatory tests. At present, the accuracy of cardiac ultrasound examination is very high. Generally, with the diagnosis of congenital heart disease by cardiac ultrasound, after detailed evaluation and planning by experts in the department, the happy surgery can be performed. In some cases of complex congenital heart disease, MRI or MRI angiography will be added. All of these tests are non-invasive. Cardiac catheterization is an invasive test and the physician will decide if it is necessary based on the condition.
18. What is the success rate of open heart surgery and what is the risk?
Although cardiac surgery is risky, for a skilled medical team, the risk of surgery for simple congenital heart disease such as atrial or ventricular diaphragmatic defects is no greater than the risk of opening an appendicitis. However, if the condition is delayed or even if it is necessary to rely on a ventilator, the risk of surgery is of course increased. The risk of other more common cyanotic congenital heart diseases such as tetralogy of Fallot is also not high. There is no reason for parents to give up and let their child lose the chance of treatment for a curable disease.
19.Should artificial materials be put in when happy tWill those artificial materials grow up with the young child tWill the artificial materials or pericardium be rejected t
Some of the happy surgeries require the implantation of artificial patches, whether it is Dacron or the patient’s own pericardium. There is no need to worry about whether they will grow with the child, because the defective part is much smaller in size than the rest of the surrounding area. The patch will of course not grow, the rest of the surrounding area will just grow. Therefore the implantation of the artificial material does not affect the development and growth of the whole heart. However, in some cases, such as disruption of the aortic arch, it is necessary to consider using the patient’s own tissue (e.g., subclavian artery) for direct anastomosis as much as possible so that the vessel can grow with the patient and avoid the need for a second surgery to replace a larger vessel later when the patient grows up. The principles of open heart surgery are the same as those of other surgical procedures, where artificial items are avoided when possible and used as little as necessary. Artificial materials are used to repair defects in the heart without fear of rejection because the endocardial epidermis grows on the surface of these materials and wraps around the outside of these materials. Therefore, it is like the patient’s own tissue and will not be rejected.
18. If I am hospitalized, how long do I have to stay?
If everything goes well, the hospital stay is approximately one to three weeks (depending on the difficulty of the procedure). Complications or more complicated surgeries may require a longer hospital stay.
19. What is the cost of open heart surgery?
Generally speaking, the cost of surgery that does not require extracorporeal circulation, such as ductus arteriosus, is about $8,000 to $10,000 including hospitalization. For those procedures that require extracorporeal circulation, the cost of hospitalization is about $12,000 to $15,000 for simple cases such as ventricular septal defect and about $20,000 to $30,000 for complex cases. The amount of cost depends on the amount of blood transfusion, the length of stay in the intensive care unit and the recovery time of the child.
20. What is the result after the surgery? Can you get married and have children in the future? What kind of industry can I work in? What do I need to pay attention to after surgery?
Most of the patients have a normal postoperative result except for an additional scar on the chest or underarm, and they can exercise and have children. In terms of work, those who have had minor surgery or who have had surgical correction can perform normal work, but avoid heavy outdoor work. There is generally nothing unusual about the post-operative period, and most people can return to their normal diet and daily life (including school) within a few weeks. Sometimes it is necessary to continue to take medication for a period of time as directed by the physician and to follow up. It is important to note that even after complete orthodontic treatment, it is still necessary to maintain dental and oral hygiene to prevent endocarditis.
Part II: Twenty Questions Before and After Valve Replacement
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Etiology and Introduction.
Rheumatic heart valve disease, also known as chronic rheumatic heart disease, is a type of heart disease with heart valve lesions that remains after acute rheumatic heart inflammation. Rheumatic heart valve disease is the most common heart disease in China, in adult cardiovascular disease, this disease accounts for about 40%, most patients are 20 to 40 years old young adults, slightly more women. Clinically, simple mitral valve lesions are the most common, accounting for 70% to 80%, and mitral valve combined with aortic valve lesions are the second most common, accounting for 20% to 30%.
Common lesions of heart valves
Indications for prosthetic heart valve replacement surgery
The indications for prosthetic heart valve replacement surgery are based on the degree of damage to the patient’s heart valves. Patients with severe valve lesions that are not amenable to prosthetic surgery should seek valve replacement surgery as long as their general condition allows. There is no absolute limit to the age of the patient. The common lesions are slightly as follows.
1, mitral stenosis: If the valve leaflets are active and only junctional adhesions or mild subvalvular damage are present, closed dilatation or direct visualization angioplasty may be pursued. If the valve is calcified or has funnel-like changes, valve replacement surgery is required.
2, mitral valve insufficiency: mitral valve annulus enlargement or junctional confinement of leaflet curl can be pursued for direct visual angioplasty. If the valve leaflet perforation, tendon rupture, etc., is difficult to correct completely or if the procedure fails, mitral valve replacement surgery is appropriate. In mitral stenosis combined with mitral valve insufficiency, most of them require valve replacement.
3, tricuspid valve damage: usually tricuspid valve does not do valve replacement surgery. Valve replacement surgery is performed only when the lesion is severe.
4, aortic valve stenosis: congenital aortic valve stenosis can often be implemented in adolescence with direct vision incision surgery, middle-aged and elderly aortic valve stenosis is mostly due to calcification on the basis of congenital aortic valve bivalve malformation. Aortic valve replacement surgery is required.
5, aortic valve insufficiency: aortic valve insufficiency can be caused by valve annulus enlargement, leaflet tear perforation, curvature or prolapse. Valve replacement surgery should usually be performed. Only mild prolapse of the aortic valve is possible to do the shaping surgery.
6, pulmonary valve lesions: mostly congenital anomalies, rarely require valve replacement, often requiring the implementation of a right ventricular-pulmonary artery diversion with a valved conduit.
Relative contraindications to prosthetic heart valve replacement surgery: rheumatic activity uncontrolled or controlled for less than 3 months; heart failure combined with myocardial ischemic damage such as patients with advanced aortic stenosis. If cardiac function has improved, surgery is still sought. Patients whose liver or kidney function or general condition is too poor to withstand surgery. Patients with bacterial endocarditis who have developed sepsis and multiple infections should not undergo surgery.
Criteria for the ideal artificial heart valve
1, the mechanical properties of the artificial valve are close to those of a natural valve, with low resistance and near-zero pressure gradient across the valve. The valve closes quickly and tightly, and there is no regurgitation. The flow field of blood through the valve is physiological, without obvious eddy flow.
2, the durability of the artificial valve should be able to achieve more than 30 years of normal work, in the whole life process after implantation of the artificial valve materials and structures, whether in chemical or physical properties can be maintained long-term stability.
3, the artificial valve has good compatibility with the body, i.e., anti-thrombotic, no destruction of blood components, no obvious rejection, and no noise. It does not affect the quality of life of patients.
4, artificial valve clinical application should be simple and easy, its material source is easy, easy to manufacture and promote.
At present, artificial heart valves are divided into two categories according to their basic performance and the materials used: all heart valves made of artificial materials are called “mechanical valves”; heart valve substitutes made of biological materials (or combined with artificial materials) are called “biological valves “.
Mechanical valves are durable and easy to implant, but they are noisy, have a more pronounced thrombogenic effect, require lifelong anticoagulation therapy, daily anticoagulant medications, and regular blood tests for prothrombin time and activity; the incidence of bleeding and thrombosis and arterial embolism caused by improper anticoagulation is higher than that of biologic valves, and once the valve is damaged or stuck, it is often too late to save it: biologic valves, on the contrary, are noiseless, have a good antithrombotic effect, and do not require lifelong anticoagulation therapy. It does not require lifelong anticoagulation therapy and has a good postoperative quality of life. However, durability is unsatisfactory, with partial valve damage in about 10 years, but valve failure allows the opportunity for reoperation for valve replacement. Although great progress has been made in the development and clinical application of artificial heart valves, and new products continue to emerge, there is not yet an ideal artificial heart valve.
Several Clinically Used Artificial Heart Valves
The prosthetic heart valve is a one-way valve that ensures smooth blood flow through the valve without backflow. It is functionally identical to the natural heart valve in the human body, but does not require a morphologic structure that mimics the natural heart valve. The prosthetic heart valve can replace the full function of the diseased heart valve, i.e., good unidirectional valve function, minimal resistance to blood flow through the valve, and no significant regurgitation; it can replace the full structure of the diseased valve; and the prosthetic heart valve must be able to be transplanted in a physiologic position.
The following prosthetic valves are now commonly used in clinical practice.
(a) biological valves
1, porcine aortic valve (glutaraldehyde treatment) porcine aortic valve structure is very similar to the human aortic valve, the source and convenient, therefore, since its introduction in 1968 this xenobiotic valve is widely used. carpentier-Edwards valve (photo) This is currently the world’s largest amount of biological valve. It is manufactured by BaxterEdwards, Inc. in the United States. Its flap frame is made of elastic alloy steel wire, wrapped with sparse polyester fabric, and the seat ring is non-circular so that it is close to the attachment edge of the flap leaf, with a larger effective opening area. A small number of porcine aortic valves are also produced and used in Beijing, Guangzhou, and Shanghai, China.
2.Bovine pericardial valve PerfeotTM valve (photo) This kind of biological valve is the latest achievement of the “Seventh Five-Year Plan” and “Eighth Five-Year Plan” medical science research undertaken by Fu Wai Cardiovascular Hospital and Cardiovascular Disease Research Institute. It is produced and promoted by Beijing Puhui Biomedical Engineering Company. Its characteristics are: long service life, in vitro accelerated fatigue test up to 500 million times; anti-calcification, chemical modification using hydroxy chromium treatment invented by our laboratory and patented by the State; good hemocompatibility, especially for patients of any age group who have difficulties in maintaining anticoagulation therapy, women of childbearing age, patients in remote areas and patients with gastrointestinal or other drug bleeding problems.
other drug bleeding problems.
(ii) Mechanical flap
1.Domestic mechanical flap Beijing GK type mechanical flap (photo) This flap was developed by Fu Wai Hospital in cooperation with the 703 Institute of the Ministry of Space and produced by the Beijing Materials Factory of the Ministry of Space. This is an oblique mechanical flap, which is characterized by the flap seat with guide hooks to control the valve body activities with holes, a breakthrough in the design of the lateral tilt type disc flap two-way bracket embedded card flap. The stent is made of titanium alloy, the disc is pyrolytic carbon coating, the valve is flat without blind area, the structure is simple, easy to process. 1985 applied to the clinical, is an excellent available artificial valve.
C-L lateral tilting disc valve (photo) This valve was developed by Changhai Hospital of Shanghai Second Military Medical University in cooperation with Shanghai Medical Research Institute and Lanzhou Carbon Factory, and produced by Lanzhou Medical Carbon Company. In 1991, the C-L lateral tilting short column flap was successfully developed, and the recent results were good after clinical trial.
2, imported mechanical flap Medtronic-Hall flap (photo) produced by Medtronic, 1977 clinical application, its structure is connected to the ring with a hook of the large flap column, its tip through the central hole of the disc, relying on the two symmetrical short flap column located in the inflow port and a single column located in the flow outlet, the joint control of disc opening and closing activities. The flattened flap is made of pyrolytic carbon and the flap frame is made of titanium alloy to ensure good mechanical strength. The valve has been used clinically in more than 100,000 cases, and the literature reports no structural failure and a low thrombosis rate, making it an excellent prosthetic valve option available today.
The Sorin valve (photo) was manufactured by Sorin Corporation and began clinical use in 1978. The St. JudeMedical bilobed valve (photo) was manufactured by St. JudeMedical, Inc. and first used clinically in October 1977. The valve is a low frame valve made of fully pyrolyzed carbon and is a central blood flow type valve. The leaflet matrix contains 10% tungsten, which allows the movement of the leaflet to be observed under x-ray, and the suture ring is made of polyester. The clinical application has been 330,000 cases, and the data prove that the incidence of complications related to the valve is also low. It is currently one of the more used prosthetic valves in the world.
Selection of prosthetic heart valves
The type of prosthetic valve used in valve replacement surgery should be analyzed on a case-by-case basis. The patient’s age, occupation, physical and mental status, the patient’s opinion on valve selection, the patient’s myocardial condition, and the patient’s ability to receive long-term anticoagulation therapy should be considered. Biologic valves have good hemodynamics, low thromboembolic rates, and may not require long-term anticoagulation in some patients; however, the greatest disadvantage of biologic valves is their poor durability. Therefore, bioprosthetic valves are mainly used in patients who are.
(i) women of childbearing age who wish to have a pregnancy.
②In terms of age, biologic valves should be preferred in patients over 60 years of age, and mechanical valves are preferred in patients under 50 years of age to ensure durability and to avoid calcification of biologic valves in adolescents.
(iii) Patients with bleeding qualities and bleeding disorders as well as other reasons for not receiving long-term anticoagulation therapy.
(iv) Biologic valves are appropriate for those who are unable to undergo anticoagulation in rural areas, depending on the patient’s financial and health care conditions.
⑤ The tricuspid valve has the highest rate of thromboembolism of all valve replacement emboli, which may be related to the low pressure and slow blood flow at this site. Clinical observations show that the rate of thromboembolism in the tricuspid valve is highest with the disc valve, second highest with the ball valve, and lowest with the biologic valve, so it is ideal to use the biologic valve for valve replacement in the tricuspid valve. The durability of mechanical valves is good, and for the time being, mechanical valves made of whatever material are implanted in the heart require lifelong anticoagulation therapy for the patient. With the advances in cardiac surgery and extracorporeal circulation technology as a whole, the safety of valve surgery has improved significantly. The mortality rate for valve replacement surgery is currently around 5%, and the early mortality rate for valve replacement surgery at Fu Wai Cardiovascular Hospital has dropped to about 2% in the last 5 years, and is not significantly related to the type of prosthetic valve. The main risk factors for valve replacement surgery are: the patient’s physical status before surgery, mainly cardiac compensatory function and pulmonary vascular disease; additional cardiac surgery, such as valve replacement with coronary artery bypass surgery, is more dangerous. Currently, it is not very difficult to operate again even if the patient is older or.