Objective To investigate the effects of thiopentone and propofol on cerebral ischemia-reperfusion injury during open heart surgery under deep hypothermia circulatory arrest in infants and young children. Methods Twenty patients with VSD and pulmonary hypertension (13 male, 7 female), aged 3-23 months and weighing 4-11 kg were randomly divided into three groups: in group A thiopentone 5mg.kg was added in CPB machine when body temperature was reduced to 30℃ (n = 7); in group B propofol 2 mg.kg-1 was added ( n =8) and group C served as control ( n - 5). When rectal temperature was reduced to 20℃, CPB was stopped and intracardiac manipulation was started. Anesthesia was induced with midazolarn 0. 2mg.kg -1, fentanyl 20 ?g.kg1 and vecuronium 0. 1mg.kg1 . After tracheal intubation the patients were mechanically ventilated and anesthesia was maintained with O2-N2O-isoflurane and intermittent boluses of fentanyl and vecuronium infusion (70?g.kg-1.h1). Radial artery was cannulated and internal jugular vein (IJV) was retrogradely cannulated until bulb, and blood samples were taken simultaneously from artery and IJV before CPB (T1 ), during circulatory arrest (T2 ) at the beginning of reperfusion ( T3 ) and 24h after operation ( T4 ) for blood gas analysis and determination of plasma concentration of lactic acid (LA), creatine kinase-BB (CKBB) activity and neuron-specific endase (NSE). Cerebral arterial-venous O2 content difference (Ca-vO2) and cerebral O2 extraction ratio (CO2ER) were calculated. Results Plasma concentration of lactic acid was increased at T3 in all three groups and was the highest in group A. Cerebral O2 metabolism decreased at T2 in all three groups and was the lowest in group B and resumed at T4 CKBB activity was increased at T3 and NSE level was increased at T3 and T4 in all 3 groups. The increase in CKBB activity and NSE level was slightest in group B. Conclusion Propofol can protect brain from ischemia-reperfusion injury in infants and young children during open heart surgery under deep hypothermic circulatory arrest.

Objective To studiy the surgical outcomes of children with congenital aortic stenosis (AS),and summarized the experience of surgical procedures.Methods From February 2006 to November 2011,a total of 49 consecutive children with AS underwent surgical treatments.Twenty-nine patients were male and 20 patients were female.The median age was 17 months (1 month to 14 years),and median weight was 15.6 kg (3.2-47.0 kg).Peak AS gradients was (74.9 ±20.4)mmHg (45-123 mm Hg) before surgery.Fourteen patients had isolated congenital AS,4 had combined moderate-to-severe aortic insufficiency (AI).Thirty-Three patients had associated cardiac anomalies,including ventricular septal defect,atrial septal defect,patent ductus ateriosus,coarctation of aorta,subaortic stenosis,and supravalvular mitral stenosis.Thirty-one patients underwent aortic valvotomy,9 valvuloplasty,2 Aortic valve replacement (AVR),1 Ross procedure,2 Ross-Konno procedure,and 4 Konno/AVR.Median follow-up was 20 months (2-55 months).Clinical and echocardiographic follow-up data were analyzed.Results There was 1 postoperative death who died of heart failure due to severe mitral valve insuffciency.Latest follow-up data showed that the survivals performed in satisfactory cardiac function.Left ventricular ejection fraction (LVEF)was 0.69 ±0.10,and fraction shortening (FS) was 0.38 ±0.09.Peak AS gradients decreased significantly after surgery to (38.6 ± 15.8) mm Hg (20-73 mm Hg),P ＜ 0.001.One patient needed reintervention because of severe recurrence of adhesion in the commissure 3 months after the previous surgery.Totally 31 patients underwent simple valvotomy procedure.Postoperative AI was none or trace in 5,mild in 20,and moderate in 6.Two surgical techniques were used to repair the aortic valve according to the anatomy of the valve and the cause of insufficiency,including commissuroplasty in 6 and pericarial casp extension in 3.Nine patients underwent valvuloplasty procedure,post-operative AI was none or trace in 3,mild in 5,and moderate in 1.We put more attention to the 7 patients who had moderate AI valvotomy or valvuloplasty,and the latest follow-up showed that these patients were in good condition and there was no deterioration the degree of AI.Conclusion Long-term outcomes show that aortic valvotomy and valvuloplasty are reliable and effective approaches for congenital AS in children.When moderate-to-severe AI exists,other procedures such as Ross,Ross-Konno,AVR,or Konno/AVR are preferred.

Objective Infracardiac total anomalous pulmonary venous connection, a rare congenital cardiac defect, is associated with high mortality. A modification was designed for the procedure to reduce the post-operative obstruction in the pulmonary venous. Methods From September 2005 to December 2007, seven patients with infracardiac total anomalous pulmonary venous connection were treated with repair surgery through right side approach. The patients' age at operation was (70.57 ±44.67) days , the weight was (4.07 ±0.87) kg. Three patients had pulmonary venous obstruction, and 2 with small PFO. A modified right - side approach for repairing this defect was used. Results No death occurred after the operation. The postoperative complications included low cardiac output in 5 patients (71.43%), pulmonary hypertension crisis in 3patients ( 42.86% ) , mechanical ventilation for more than 7 days, which happened in 2 patients (28.58%) and pulmonary infection. All of the patients received follow-up. No residual shunt and pulmonary venous return obstruction were identified on echocardiogram(with a velocity from 1.2 m/s to 1.47 m/s). The heart function of patients was within the normal range(EF 0.70 -0.79, FS 0.32 -0.44). Conclusion The modified surgical procedure for the correction of infracardiac total anomalous pulmonary venous connection by right side approach was associated with favorite clinical outcomes, The post-operative outcomes depended on the size of anastomosis between the common vein and left atrium and the patency of the pulmonary venous return. Adequate size of anastomosis and maintenance of the spatial structures in adjacent regions were helpful in decreasing the adverse effect of postoperative obstruction.

Objective A retrospective review of the use of delayed sterna closure (DSC) after pediatric cardiac operations.The purpose of this study is to access the morbidity of DSC and to analyze the risk factors that may predict the need for DSC.Methods Between January 2008 and December 2011,5 546 infants (2 843 males,2 703 females) underwent cardiac operations through midterm sternotomy in Shanghai Children' s Medical Center.Median age was 5 months(1 day to 11 months) and mean weight was 6.1 kg(2.0-12.5 kg).The pathologies included transposition of great artery(TGA),corctation of aorta (CoA),interruption of aortic arch (IAA),pulmonary atresia (PA),truncus arteriosus (Truncus),complete atrioventricular septal defect(CAVSD),total anormalous pulmonary vein connection (TAPVC),double outlet of right ventricle(DORV),tetralogy of Fallot(TOF),and ventricular septal defect(VSD),et al.All hospital records were reviewed and clinical data were studied and analyzed.Results A total of 313 patients had DSC (5.6％).There were 191 males and 122 females.The reasons for DSC are hemodynamic instability in 296,bleeding in 11,and ECMO(or VAD) in 6 patients.Two hundred and fiftyone (80.2％) patients were less than 5 kg,84 (26.8 ％) patients were neonates,and 125 (39.9％) patients aged between one and three months old.The incidences of DSC for these patients were 13.9％,34.4％,and 18.4％ respectively.The diagnosis of complex congenital heart defects had a high risk of DSC.The incidences of DSC for TGA,CoA,IAA,PA,Truncus,CAVSD,TAPVC,and DORV were 28.8％,17.8％,43.1％,9.0％,30.4％,6.5％,and 10.8％ respectively.The DSC patients had longer duration of CPB time(147 min versus 72 min) and clamping time(81 min versus 40 min).In 282 patients the sternums were closed 1-11 days after the initial operation.In 3 cases the trial of closure failed for the first time and succeeded a second time until several days later.Fouty-six patients died ultimately including 15 patients died after the closure of sternum with a total mortality of 14.7 ％.Surgical site infection occurred in 17 patients (5.4％),and surgical intervention were needed in 4 severe cases(1.3％).Conclusion Neonates,an age less than 3 months,weight less than 5 kg,long CPB time and clamping time,and the diagnosis of complex congenital heart defects were risk factors of the need for delayed sterna closure after pediatric cardiac operations.

Objective:To summarize the morphological characteristics and clinical experience of pulmonary artery sling(PAS) combined with anomalous bronchial branching, and provide new considerations for surgically treating PAS.Methods:A retrospective review of surgical experience of all patients with anomalous bronchial branching from January 2012 to December 2018 at Shanghai Children's Medical Center was conducted. There are 4 types according to the morphology of anomalous bronchial branching: tracheal bronchus, bronchial trifurcation, bridging bronchus, tracheal bronchus combined with bronchial trifurcation. The proportion of patients with anomalous bronchial branching combined with PAS was counted. The rate of tracheoplasty for four types was determined. We measured the interbronchial and subcarinal/subpseudocarinal angles before and after tracheoplasty.Results:140 patients were included in our study. The tracheal diameter of 11(21%, 11/53) patients with tracheal bronchus and 4(9%, 4/44) patients with bronchial trifurcation was normal. Among these patients, 125 patients had congenital tracheal stenosis(CTS). 115 patients underwent tracheoplasty. The rate of tracheoplasty of bridging bronchus was higher than tracheal bronchus(100% vs. 60%, P=0.000). One-stage surgery was performed in 76(61%) patients who had PAS. The interbronchial and subcarinal/subpseudocarinal angles were significantly reduced postoperatively( P=0.000). Conclusion:It is difficult to explain merely with vascular compression in patients with PAS with CTS and anomalous bronchial branching. One-stage slide tracheoplasty is currently the optimal option.

Objective To explore risk factors of cardiac surgery in neonates with low body weight.Methods Retrospective analysis was made in neonates weighing less than 3 kg at surgery(n =192;group 1) and 3 to 6 kg(n =517;group 2),who had undergone open cardiac repairs from January 2006 to December 2015 at our institution.Patients were grouped according to the primary procedure performed and analyzed according to their weight at the time of surgical intervention.Patients were also analyzed according to preoperative risk scores.Univariate versus multivariate risk analysis was performed.Results Hospital early mortality in group 1 was 25.0％ (n =48) versus 14.5 ％ (n =75) in group 2 (P =0.001).Compared with group 2,neonates in group 1 had a significantly higher mortality for simple arterial switch procedure.Lower body weight remained strongly associated with mortality risk after stratifying the population by preoperative risk scores category levels 2.Within group 1,age,weight at surgery,preoperative risk score and type of procedure were not associated with significant differences in early mortality.Cardio-pulmonary bypass time,aortic cross-clamp time and the presence of a surgical complication were independent risk factors for early mortality in group 1.Conclusion Among neonates weighing less than 3.0kg who underwent open cardiac surgery,perioperative hemodynamic status,reflected by bypass time,cross-clamp time,and surgical complications,strongly influenced early mortality.In contrast,low body weight itself was not associated with early mortality.

Objective To investigate the clinical efficacy of pancreaticoduodenectomy (PD) and duodenumpreserving pancreatic head resection (DPPHR,including Beger,Frey and Berne procedures)for the treatment of chronic pancreatitis (CP) with mass in the head of the pancreas.Methods The clinical data of 48 patients with CP who were admitted to the Armed Police Corps Hospital of Hunan province(13) and the Third Xiangya Hospital of Central South University (35) between January 2007 and December 2013 were retrospectively analyzed.The operation methods were selected according to clinical symptoms,imaging findings and intraoperative pathological examinations.Twenty-three patients receiving PD (Whipple procedure or pylorus-preserving PD) were allocated into PD group and 25 receiving DPPHR (Beger,Frey and Berne procedures) were allocated into DPPHR group.The operation time,volume of intraoperative blood loss,rate of postoperative pain relief,changes of pancreatic endocrine and exocrine function,complications,duration of hospital stay and hospital expenses in the 2 groups were analyzed.Patients were followed up by telephone interview and outpatient examination up to September 2014.Measurement data with normal distribution were presented as (x) ± s.Comparison between groups was analyzed using the t test.Count data were analyzed using chi-square test or Fisher exact probability.Results Of the 23 patients in the PD group,15 patients received Whipple procedure and 8 patients received pylorus preserving PD.Of 25 patients in the DPPHR group,8 patients received Beger procedure,13 patients received Frey procedure and 4 patients received Berne procedure.The operation time and volume of intraoperative blood loss were (5.5 ± 0.4) hours,(372 ± 174) mL in the PD group,and (4.2 ± 0.6) hours,(272 ± 114) mL in the DPPHR group,showing significant differences between the 2 groups (t =8.712,2.375,P ＜ 0.05).Three patients had massive hemorrhage in the PD group and 2 patients receiving Beger procedure had massive hemorrhage due to portal vein injury,with no significant difference (x2=0.010,P ＞ 0.05).The intraoperative pathologic examinations of frozen section showed chronic inflammation in all pancreatic tissue samples with fibrous tissue proliferations.Overall pain relief rate was 95.7％ (22/23) in the PD group,including 20 complete remissions and 2 partial remissions,and overall pain relief rate was 92.0％ (23/25) in the PD group,including 18 complete remissions and 5 partial remissions,which were no different in overall pain relief rate (x2 =0.000,P ＞ 0.05).The morbidity of postoperative diabetes mellitus and dyspepsia with fatty diarrhea were 38.9％ (7/18) and 35.7％ (5/14) in the PD group,which were no different from 9.5％ (2/21) and 20.0％ (3/15) in the DPPHR group (x2=3.200,0.281,P ＞0.05).The incidence of postoperative complication was 30.4％ (7/23) in the PD group,including 1 case of intra-abdominal hemorrhage,pancreatic fistula and localized peritonitis,1 case of pancreatic fistula,2 cases of biliary fistula,3 cases of delayed gastric emptying.Patients with pancreatic fistula and biliary fistula recovered after 1-week sufficient drainage.The incidence of postoperative complication was 4.0％ (1/25) in the DPPHR group,including 1 case of pancreatic fistula,showing significant difference in incidence of postoperative complication (x2=4.274,P ＜ 0.05).The duration of postoperative stay and hospital expense were (12.4 ± 2.5) days and (57 751 ± 6 772) yuan in the PD group,which were significantly different from (8.2 ± 1.8) days and (49 109 ± 6 168)yuan in the DPPHR group (t =6.576,4.645,P ＜ 0.05).Forty-eight patients were followed up with a median time of 51.6 months (9.0-92.0 months).Of the 2 patients died,1 patient who underwent Frey procedure died 3 months after diagnosis of pancreatic cancer due to epigastric pain at postoperative month 6,the other died 2 years later due to cardiovascular disease.Among 48 patients with follow-up,1 received biliary-intestine drainage 6 months later and other patients had no recurrence or canceration.Conclusions DPPHR is safe and effective for chronic pancreatitis with mass in the head of the pancreas,having advantages such as shorter duration of operation,less intraoperative hemorrhage,faster postoperative recover,shorter duration of hospital stay and delayed hypofunction of pancreatic endocrine and exocrine function.But DPPHR cannot completely replace PD,It is necessary to master indications for all kinds of operations and choose proper operative approaches based on lesion characteristics.

Objective To analyze the clinical effect of pedicle screw fixation in the treatment of multi-segmental lumbar fracture and dislocation under the guidance of visualization technique. Methods A total of 21 patients with multi-segmental lumbar fracture and dislocation were selected from November 2012 to November 2013. Before the screw implantation, the structure of bilateral pedicle was observed through Mimics software and the implantation parameters were measured. The position of pedicle screws by postoperative CT scan, operation time, and the satisfaction of the patients were assessed. The percentages of anterior vertebral height and Cobb′s angle were measured before operation, 2 weeks and 8 months after operation. Results All patients were satisfied with informed consent score and the way of pedicle screw and the selection of plant were more reasonable. With better screw position, shorter operative time and less blood loss and adverse reactions, pedicle screw fixation achieved good effect. Conclusion With high security and considerable clinical value, pedicle screw fixation in the treatment of multi-segmental lumbar fracture and dislocation under the guidance of visualization technique has exact and good effecct.

Objective:To analyze the early postoperative mortality and long-term reoperation of ASO and to explore the surgical risk and the reasons of long-term reoperation.Methods:The clinical data and follow-up data of ASO children undergoing surgery in Shanghai Children Medical Center from January 2010 to December 2020 were analyzed retrospectively. Four groups were divided into transposition of the great vessels(TGA/IVS) , transposition of the great vessels with ventricular septal defect(TGA/VSD) , Taussig-bing anomaly(TBA) , and two stage ASO(Ⅱ-ASO) groups. χ2 test was used to analyze the early mortality and long-term reoperation rates of ASO in different groups. Results:A total of 861 ASO patients were included in this study and 108 died early(12.5%, 108/861) . Seven hundred and fifty three cases were followed up and 102 cases were lost(13.5%, 102/753) . The median follow-up time was 7.23 years and the quartile interval was 4.74-9.37 years old. Sixty six patients(10.1%, 66/651) underwent long-term reoperation. Four patients(6%, 4/66) died after reoperation. In 241 cases of TGA/IVS, 24 cases(10%) were performed reoperation. In 256 cases of TGA/VSD, 23 cases(9%) had reoperation. In 126 cases of TBA, 18 cases(14.3%) for reoperation. And in 28 cases of Ⅱ-ASO only 1 case(3.6%) had reoperation. Among all the reoperation cases, there were 36 cases(2 deaths) for pulmonary angioplasty, 2 cases for pulmonary stenting, 10 cases for right ventricular outflow tract obstruction(RVOTO) repair, 2 cases for aortic valvularplasty, 5 cases for aortic valve replacement(2 deaths), 4 cases for aortic anastomotic stenosis repair, 3 cases for left ventricular outflow tract obstruction(LVOTO) repair, 2 cases for VSD residual shunt repair and 2 cases for coarctation of the aorta(CoA) correction.Conclusion:The early mortality rate of ASO surgery is still higher than that of developed countries. Long-term follow-up after ASO surgery should focus on right ventricular outflow tract stenosis and aortic valve insufficiency.

Objective:Explore a predictive model for predicting postoperative hospital mortality in children with congenital heart disease.Methods:We retrospectively analyzed the characteristics of all children with congenital heart disease from January 1, 2006 to December 31, 2017 at Shanghai Children's Medical Center. Each procedure was assigned a complexity score based on Aristotle Score. In-hospital death prediction models including a procedure complexity score and patient-level risk factors were constructed using logistic regression analysis and machine learning methods. The predictive values of the models were tested by C-index. Results:A total of 24 693 patients underwent CHD operations were include in the study, there were 585 (2.4%) in-hospital deaths. In-hospital mortality for each procedure varies between 0 to 77.8%, with 32 procedures with 0 death record. The prediction model constructed using logistic regression found that in addition to the complexity score, other risk factors included age, height, operation history, echocardiography characteristics as well as certain laboratory test results (mainly coagulation factors) were significantly correlated with in-hospital death. Receiver operating curve analysis showed that prediction with only the complexity score resulted in an AUC of 0.654 (95% CI: 0.628-0, 681, P<0.01) while model containing patient-level risk factors had significant higher prediction value with AUC of 0.886 (95% CI: 0.868-0.904, P<0.01). Training with machine learning method resulted in a final prediction model with high prediction value ( AUC 0.889, with a sensitivity value for death prediction of 0.817). The key risk factors in machine learning model are in general agree with the logistic regression model however with subtle differences. Conclusion:Through combination of procedure complexity score with pre-operative patient-level factors, predictive model constructed using regression or machine learning method had high accuracy in in-hospital mortality prediction.