Treatment of congenital heart disease.
Congenital heart disease is a cruel “killer” that endangers the health and life of children, especially infants and young children. According to statistics, the incidence of congenital heart disease is about 6 ‰ to 8 ‰, based on the number of 25 million births each year, there are about 150,000 to 200,000 newborns with congenital heart disease in China, and ventricular septal defect, atrial septal defect, patent ductus arteriosus, tetralogy of Fallot and pulmonary valve stenosis are the most common clinical congenital intracardiac malformations. Due to the lack of effective preventive measures for congenital heart disease and the fact that 1/2 of untreated congenital heart disease die by the age of one and 2/3 by the age of two, the natural prognosis is poor; however, in fact, except for a small percentage of congenital heart disease that can be cured spontaneously or severe malformations that cannot be corrected, more than 2/3 of congenital heart disease can be cured or improved by different treatments. Therefore, early detection, early diagnosis and early treatment are the keys to reduce the natural mortality of this precocious disease. At present, the treatment of precordial disease includes the following.
1.Internal medicine treatment.
The internal treatment of precardiac disease can not correct the anatomical malformation of cardiovascular, mainly to treat some complications and comorbidities of precardiac disease, such as prevention and control of infective endocarditis, respiratory tract infection, pulmonary hyaline membrane disease, heart failure, brain abscess; or use drugs (such as prostaglandin E) to maintain the opening of life-dependent arterial ducts to increase pulmonary blood flow and improve hypoxia, but for pulmonary congestion, pulmonary hypertension of precardiac disease Anti-inflammatory pain tablets 0.2-0.3 mg. kg-1 or aspirin tablets 20 mg. kg-1 orally four times a day can be used to inhibit prostaglandin synthesis to close the ducts and reduce pulmonary hypertension due to increased pulmonary blood. The anti-inflammatory pain has side effects such as causing transient hematuria, renal dysfunction and bleeding, so it should be closely observed during the medication.
2.Surgical treatment.
Surgery is the traditional method for the treatment of precordial disease, and there has been very rich experience and good therapeutic effect. Although many precordial diseases can be cured by interventional methods, surgery is still the main means of treating precordial disease. Previously, because the technology of extracorporeal circulation, anesthesia, and postoperative monitoring was not perfect, the development of extracorporeal circulation surgery was restricted by the age and weight of the child, which made the condition of many precardiac diseases develop and change with age, missing the best time for surgery and affecting the long-term prognosis or natural death before waiting for surgery. In addition, many precocious heart disease in the neonatal, infant and early childhood there is respiratory insufficiency, heart failure or severe hypoxemia and other critical conditions, if not actively intervene, the natural mortality rate is high, in principle, should be operated as early as possible, even if not radical, for some complex or difficult cases can also be created through interventional treatment, palliative surgery to the second stage of radical treatment opportunities, as long as the timing of treatment, the right method, most of the precocious heart disease is possible As long as the timing and method of treatment are appropriate, most of the precardiac diseases can be cured by surgical treatment.
Regarding the age at which surgery is most appropriate for congenital heart disease, the age of surgery should be decided according to the type of congenital heart disease and the early and late appearance of symptoms. At present, surgery for congenital heart disease can be divided into three categories.
①Emergency surgery: If the malformation is serious, the impact on hemodynamics is obvious, the child’s symptoms appear early, heart failure and endocarditis occur repeatedly, and life is at risk, surgery can be performed as early as possible regardless of age, and in some cases, surgery is even performed in the neonatal period.
② Elective surgery: the condition of these children is often not very critical, and a suitable time should be chosen for surgery under the condition of ensuring the safety of surgery. Most children with congenital heart disease should undergo surgery at the age of 1-6 years old, or at the latest before school age, which will not affect the child’s schooling and can reduce the burden on society and family.
③ Waiting for surgery: Some congenital heart diseases have the possibility of self-healing, such as unclosed oval foramen with diameter less than 5mm, ventricular septal defect, and unclosed arteriovenous duct, etc. If there is no tendency of self-closing during clinical observation, surgery will be considered again. The condition of this part of patients is often mild and the impact on the child’s organism during observation is less. In conclusion, congenital heart disease is a progressive disease, and the principle of surgery should be based on the local situation and the condition of the child, and the sooner the surgery is done, the better, and as far as possible, radical surgery is performed, while ensuring the safety of the surgery.
Radical surgery can be divided into radical and palliative surgery, and radical surgery can be divided into anatomic radical treatment (such as ventricular defect repair, atrial defect repair, arterial catheter ligation, etc., which can restore normal anatomical structure after treatment) and hemodynamic radical treatment (such as total cavopulmonary artery anastomosis and various types of Fontan surgery, etc., which can restore normal blood circulation pathways after treatment, but cannot restore normal anatomical structure); palliative surgery mainly includes Procedures to increase pulmonary blood (such as Blalock-Taussig procedure, two-way Glenn procedure), reduce pulmonary blood (such as Banding procedure) and increase intracardiac blood mixing (such as Rashkind procedure, Blalock-Hanlon procedure, etc.).
3.Interventional treatment.
Open chest is the traditional surgical method, but because of the surgical trauma and the physiological impact of extracorporeal circulation on the body, with the development of medicine, interventional treatment without open incision is more and more widely used in the treatment of precordial disease. 1967 foreign experts Porstmann and others took the lead in successfully plugging the unclosed arterial duct by the interventional catheter method, after which the method was successively applied to the atrial septal defect, pulmonary valve stenosis, etc. In particular, with the development of medicine and related disciplines in recent years, congenital ventricular septal defects can also be treated radically by interventional catheterization. The interventional treatment of these diseases is similar in that a large vessel is punctured at the root of the thigh and a special catheter is delivered along the vessel to the location of the cardiac lesion for treatment (blocking or dilation), which is generally applied to patients over 2 to 3 years of age.
Compared with traditional open-chest extracorporeal circulation surgery, interventional treatment has the following advantages.
①No need to open the chest, no cut marks on the chest, small trauma and aesthetic;
②No need for extracorporeal circulation, children’s physique is different from that of adults, avoiding the risks associated with extracorporeal circulation; less intraoperative blood loss, no need for blood transfusion; fewer complications, high safety;
③Short hospitalization time, fast recovery, and no need to take any drugs after surgery;
④Good treatment effect: 1 month after the blocker is implanted in the heart, the body’s own endothelial cells will have covered the surface, and after 3 months, the endothelial cells will completely encapsulate the blocker and the blocker will not fall off. The disadvantages are that there is an age limit, only a few types of disease can receive this treatment, and most of the materials used are imported and expensive. This kind of interventional treatment for precardiac disease has been improved through clinical practice and is now basically mature, and after several years of follow-up observation, it is found that patients with precardiac disease who have undergone interventional treatment can be completely restored to normal, and their growth and development are not affected, and they are able to perform all work, study and life.
4.Hybrid technology (medical and surgical mosaic treatment).
Internal and surgical mosaic treatment is to correct congenital heart disease with intraoperative transthoracic interventional therapy. Although surgery is still the main means of treatment of congenital heart disease, but in the past two decades, with the development of interventional technology, more and more heart disease can be solved by interventional means. Although surgical procedures for congenital heart disease are effective, they often require extracorporeal circulation technical support and have a greater impact on the internal environment of the body. Hybrid technology, which is also known as the medical and surgical mosaic treatment of precardiac disease, has become one of the development directions and hot spots in the field of cardiac surgery.
Hybrid technology should have the operability of both surgery and intervention, and the main indications include.
① Use of interventional techniques before and after surgical treatment to create conditions for staged surgery or for post-surgical remedy;
(ii) Correction of deformities by small incisions in the chest or with the assistance of thoracoscopy and under the guidance of imaging using interventional devices in combination with conventional surgical procedures, mainly dilation and sealing, such as balloon dilation of pulmonary stenosis, sealing of atrial septal defects, ventricular septal defects, etc;
Hybrid technique has the following advantages compared to surgical procedures.
①The application of this technology does not split the sternum, the heart does not stop beating, avoiding extracorporeal circulation and reducing surgical trauma;
(2) Intraoperative interventions are used to shorten the operation time and reduce the risk of surgery, and the patient recovers quickly;
③Interventional treatment under real-time ultrasound guidance, while the treatment effect can be observed.
④The combination of thoracoscopic or small incision techniques can ensure aesthetics. It also has certain advantages compared with medical interventions.
(i) the constraints of peripheral vascular conditions on the application of interventional techniques can be avoided, and children with more severe disease can be operated as early as possible regardless of age;
(ii) The combination of other malformations can be treated simultaneously, solving problems that cannot be solved by intervention alone;
(3) Different pathways can be chosen to operate on the heart in close proximity, which is safe and has a high success rate. (3) Different pathways can be selected to perform the operation in close proximity to the heart, which is safe and successful;
④The intervention is performed under real-time ultrasound guidance, avoiding the influence of radiation;
⑤ In case of unexpected situation, open-heart surgery can be performed.