Congenital heart disease has been an important part of congenital diseases in infants and children, and the incidence rate has been maintained at about 1%. In other words, for every hundred children born, there is one child with congenital heart disease. Congenital heart diseases are subdivided into simple congenital heart diseases (such as atrial septal defect, ventricular septal defect, and patent ductus arteriosus, etc.) and complex congenital heart diseases (such as tetralogy of Fallot, pulmonary atresia, complete transposition of the great arteries, and complete endocardial cushion defect, etc.). For most complex precardiac diseases, because of the limited effectiveness of surgical treatment, both physicians and the child’s family tend to consider more the outcome of the treatment and the child’s long-term prognosis, and may have no choice about the aesthetics of the incision and the size of the trauma of the treatment plan. However, surgical treatment of simple precordial disease has a history of up to 60 years, and in the last decade, a variety of new and minimally invasive treatment modalities (such as percutaneous atrial septal defect closure and transthoracic small-incision atrial septal defect closure) have emerged. Therefore, the size of the trauma, the choice of incision, and the presence of foreign body residue in the body are now the main concerns of the families of children with simple precordial disease. Most parents have doubts about the choice of traditional open-heart surgery, small-incision open-heart surgery (lower sternal incision, right axillary incision, etc.), open-heart interventional occlusion and percutaneous interventional occlusion, and are often confused by hearsay and half-understanding. The following is a detailed analysis of the advantages and disadvantages of these four treatment options for children with ventricular septal defect to help you choose the best treatment option for your child.
I. Percutaneous ventricular septal defect occlusion
Percutaneous ventricular septal defect occlusion is a procedure in which a catheter is sent along the aorta through the femoral artery (the large artery at the root of the thigh) to the heart to complete the release of the blocking umbrella, which clamps the ventricular septal defect and closes the ventricular septal defect (the specific route and the shape of the blocking umbrella are shown in the figure above).
Advantages: 1. Minimally invasive. This procedure does not require open chest, no surgical incision, no extracorporeal circulation, short anesthesia time, and can be discharged 1-3 days after the placement of the blocking umbrella, with minimal trauma and fastest recovery.
2.Aesthetic. Only a small puncture point at the root of the thigh, basically no scarring.
Disadvantages: 1. limited patient selection: limited to children over 3 years of age (a sufficiently thick femoral artery implant catheter is required); there are harsh requirements for the location of the ventricular defect, and it is extremely difficult to occlude the tricuspid valve, adhere to the tricuspid valve, or seal the subcristal or subdry ventricular defect.
2. the need for intraoperative contrast and fluoroscopic guidance, which can cause a large amount of contrast agent (hepatic and nephrotoxic) to enter the body and absorb a large amount of radioactive rays (X-rays, excessive intake may affect the development of the nervous system and reproductive system of young children and increase the incidence of malignant tumors such as leukemia).
3. Inability to detect and manage other combined malformations. At present, most of the precordial diseases rely on echocardiography to confirm the diagnosis. Echocardiography determines the structure and blood flow of the heart through the echo of ultrasound in the heart, with an accuracy of over 99%. However, there are still chances of misdiagnosis and missed diagnosis. If other malformations are combined, this procedure can only seal the ventricular septal defect but cannot deal with other malformations, which may require open-heart surgery again.
4. The incidence of complications related to ventricular defects is high. In order to successfully seal the ventricular septal defect, the diameter of the blocking umbrella is usually 2-3 mm larger than the diameter of the ventricular septal defect, and due to the remote operation of the guidewire through the femoral artery, the blocking umbrella may be displaced and dislodged when it is released, requiring surgical open-heart surgery (since March 2014, our ward has completed 3 emergency surgeries in which the blocking umbrella was dislodged due to percutaneous blocking, which endangered the life of the child); the blocking umbrella is made of metal and is hard. The blocking parachute is made of metal, which is hard and may compress the cardiac conduction tissue around the ventricular defect after release, resulting in a significantly higher rate of third-degree AV block requiring a permanent pacemaker or distant arrhythmias compared with open surgery; the blocking parachute is large in diameter and has little control over remote operations, which may easily damage the surrounding tricuspid valve, aortic valve and other adjacent valves, resulting in valve damage or incomplete closure, requiring surgical valve replacement after several years. surgical valve replacement surgery.
5, anticoagulation-related problems. This procedure involves the placement of a metallic foreign body in the heart, which will be recognized by normal human tissues and produce a coagulation reaction, forming a thrombus with the foreign body as the focal point, which will lead to serious complications such as cerebral infarction, heart attack, pulmonary embolism, etc. Once dislodged, aspirin anticoagulation is required for at least 3 months after surgery, during which coagulation-related bleeding complications may occur.
6. The procedure is only about ten years old so far. In the last decade, the results have been good, and no significant long-term complications have emerged. However, the lack of long-term bulk studies supported by evidence-based medical significance, thirty, forty or even fifty years later there may be complications that are currently unpredictable (an example: myopia correction surgery is now thirty years old, the results are very good, but still visible ophthalmologists mostly with glasses, why, is the lack of long-term follow-up data to support the long-term safety of the procedure).
7, the body is placed in the metal foreign body, in the future over the security check and other body checks with others, may have a certain impact on the child’s psychology. At present, the rapid development of science and technology, may be a few decades after the emergence of the magnetic levitation transport in the film, electronic tags, electronic signals, electronic identification and other technologies are integrated into people’s daily life, the body of the metal foreign body may have a greater impact on the future life of the child.
Small transthoracic incision for ventricular septal defect occlusion
The core treatment method is the same as that of percutaneous occlusion, in which the blocking umbrella is released in the heart through a catheter to close the defect. The difference is that a small incision of typically 2-4 cm next to the sternum is chosen and the catheter is placed through the ventricular surface (as shown above).
Advantages: 1. Less invasive. This procedure does not require a longitudinal sternum, the surgical incision is smaller, no extracorporeal circulation is required, anesthesia is short, recovery is faster, and the blocking umbrella can be discharged 3-5 days after placement with less trauma and faster recovery.
2. More beautiful. The wound of the child is on the left side of the lower end of the sternum, with a scar of 2-4 cm, which is relatively hidden.
3.Wider scope of application. The change of catheter access reduces the restriction on the age and weight of the child, and small incision transthoracic occlusion is generally feasible for children over 1 year old.
4. Transesophageal ultrasound guidance is used to determine the location and timing of release of the blocking umbrella through ultrasound to avoid damage to the child from radiation and contrast agent.
Disadvantages: 1. slightly limited patient selection: limited to children over 1 year of age (no blocking umbrella of corresponding size for small children); more demanding requirements for the location of the ventricular defect, which is obscured by the tricuspid valve, adherent to the tricuspid valve, and extremely difficult to block the subcrestal and subdry ventricular defects.
2. It is not possible to detect and manage other combined malformations. At present, the diagnosis of precordial disease is mostly confirmed by echocardiography, which determines the structure and blood flow of the heart by the echo of ultrasound in the heart, with an accuracy of more than 99%. However, there are still chances of misdiagnosis and missed diagnosis. If other malformations are combined, this procedure can only seal the ventricular septal defect but not the other malformations, which may require another open-heart surgery.
3. The incidence of complications related to ventricular defects is high. The reasons for this are the same as above.
4, anticoagulation-related problems (specific as above)
5, the shortest time to date for this procedure. So far, the results are good and no significant long-term complications have occurred. However, there is a lack of long-term bulk studies with evidence-based medical significance to support the possibility of currently unpredictable complications after thirty, forty or even fifty years.
6, the body placed in the metal foreign body, in the future through security and other body checks with others, may have a certain impact on the child’s psychology. At present, the rapid development of science and technology, it is likely to appear in a few decades that the magnetic levitation transport in the movie, electronic tags, electronic signals, electronic identification and other technologies are integrated into people’s daily life, the metal foreign body in the body is likely to have a greater impact on the patient’s life in the future.
Third, the traditional surgical treatment
Traditional surgical open-heart surgery began in the 1950s, the surgical effect is indeed, no obvious serious complications in the long term. However, its status has been severely challenged by the emerging types of interventional surgery due to the large trauma.
Advantages: 1. The widest range of application. Regardless of age, location of the ventricular defect, and whether it is combined with other malformations such as tricuspid insufficiency, all can be treated by this procedure.
2. The most definite long-term results. This procedure has a history of seventy years, with a large sample size of evidence-based evidence perfected after surgery, with very good surgical results and no significant long-term complications.
3, low complication rate. With the rapid development of anesthesia and extracorporeal circulation technology in recent years, the impact of extracorporeal circulation and anesthesia on the child in simple precordial surgery is minimal and almost negligible, and the risk of surgery is less than 1 in 1,000; much higher than all kinds of blocking surgery.
4.No radiation and contrast agent damage.
5.No foreign body in the body, no need for anticoagulation treatment, no hidden danger of affecting life in the future.
Disadvantages: 1, the most traumatic. Requires median longitudinal splitting of the sternum, establishment of extracorporeal circulation, cardiac arrest, cardiac incision, long operation time, slow recovery, usually 5-7 days discharge, postoperative need to take cardiac diuretic drugs 1-3 months, full recovery takes 3 months – 6 months.
2. The scar is huge and affects the aesthetics. About 10-15 cm surgical incision in the middle, with obvious postoperative scar (as shown above), which has a certain impact on the psychology and future life of the child, especially significant for girls.
3. The cost may be slightly higher than that of blocking surgery (choose domestic blocking umbrella).
IV. Small incision open-heart surgery
Therefore, in the past ten years or so, surgeons have started to look for minimally invasive surgery based on surgery to improve the incision access, reduce scarring and trauma, and so far, the small incision in the lower sternum and the right axillary incision are the most mature and accepted by the families of children.
Advantages: 1. Slightly less traumatic. Compared with traditional surgery, the operation time and the degree of sternal destruction are significantly improved, and it is not necessary to completely split the sternum (lower small incision) or even damage the bony structure of the thorax (right axillary incision), and the hospital stay is about 5 days, and the full recovery takes 3 months.
2.Smaller scar, more beautiful. The surgical incision is generally 3-5cm, similar to the size of the incision for transthoracic interventional blocking treatment, which is more concealed (the above three photos are the postoperative incision photos of several patients I have recently completed, the left side is the photo of the patient with a lateral incision, and the two photos on the right side are the photos of the small incision at the lower end of the sternum), and the satisfaction of the child’s family is very high.
3. At the same time, it has the advantages of traditional surgery such as wide range of surgical adaptation, low complication rate, no foreign body residue and exact long-term effect.
Disadvantages: Although it is an improvement over traditional open-heart surgery, the trauma is still somewhat greater than the two blocking techniques, and the recovery time is longer.
In summary, different treatment options have their inherent advantages and disadvantages, and parents should choose according to their child’s condition and their own requirements in all aspects. We hope that the above information will help you in your choice of surgical options. If you are not sure about your child’s condition, please feel free to leave a message online or call us for more information.
Finally, I wish all children with the disease a speedy recovery and healthy growth as normal children!
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