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    Editorial
    Development and suggestions for pediatric cardiac surgery in China
    DING Wen-xiang
    2011, 31 (9):  1219. 
    doi: 10.3969/j.issn.1674-8115.2011.09.001

    Abstract ( 1515 )   PDF (1876KB) ( 985 )  

    Since the establishment of Department of Pediatric Congenital Heart Surgery in 1974, the surgical technique for complicated congenital heart diseases has reached the advanced international level. However, there is room for improvement in some issues such as regional differences, medical insurance and medical policy. Besides, the localization of specialized equipment should be enhanced. This paper describes the current status of pediatric cardiac surgery in China.

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    Progress and challenge of pediatric congenital heart surgery in China
    LIU Jin-fen, DING Wen-xiang
    2011, 31 (9):  1221. 
    doi: 10.3969/j.issn.1674-8115.2011.09.002

    Abstract ( 1816 )   PDF (5270KB) ( 1337 )  

    Congenital heart disease (CHD) is a category of severe illness threatening children's health. However, favorable outcome can be achieved with proper management. Unfortunately, CHD remains a health challenge for children and families in many developing countries due to insufficient medical resource. During the past 30 years, the management of pediatric CHD has been greatly improved in China. Specifically, Project HOPE has played an important role in facilitating the collaboration between Shanghai Children's Medical Center and many world'leading pediatric health care institutions, which has provided valuable opportunity to enable the growth of Shanghai Children's Medical Center into a state-of-theart hospital.

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    Progress of surgical treatment of pediatric congenital heart disease
    XU Zhi-wei
    2011, 31 (9):  1226. 
    doi: 10.3969/j.issn.1674-8115.2011.09.003

    Abstract ( 1411 )   PDF (5587KB) ( 1386 )  

    In recent years, the surgical treatment and operative procedure for congenital heart disease (CHD) have been greatly improved. The surgical results of hypoplastic left heart syndrome (HLHS) have been improved by modified operative procedure and intervention. With proper management of the right ventricle outflow tract in tetralogy of Fallot (TOF), right ventricle heart function can be improved after operation. The surgical repair of pulmonary venous obstruction after operation of total abnormal pulmonary venous connection (TAPVC), and the renewed operative procedure of transposition of the great arteries (TGA) and congenital corrected transposition of the great arteries (ccTGA) facilitate the rational surgical treatment of complex CHD. With improvement of operative procedure for CHD, the operative successful rate is increased, the incidence of complications is decreased, and the quality of life and long-term surgical outcomes are improved.

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    Progress and perspective of new interventional techniques in treatment of congenital heart disease
    LI Fen
    2011, 31 (9):  1231. 
    doi: 10.3969/j.issn.1674-8115.2011.09.004

    Abstract ( 1873 )   PDF (4159KB) ( 1535 )  

    The field of interventional cardiology for congenital heart disease has experienced considerable progress in the last few years. Transcatheter closure of congenital heart defect is now a well-established procedure, but potential dangers of a foreign object in the body are still concerned. Bioabsorbable device aiming at leaving little or no foreign material behind remains promising alternatives for the future. Percutaneous valve replacement has received tremendous interest as a direct result of advancement in endovascular techniques. With further development and improvement, this technique is expected to be used routinely in clinical practice. The "hybrid" approach, a novel strategy to congenital heart disease, allows surgeons and interventional cardiologists to combine their expertise and provide the best approach to correct or palliate these defects with optimal outcomes. This concept may enable new treatment options, especially in patients with complex congenital heart defects.

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    Advances and clinical application of fetal echocardiography
    ZHANG Yu-qi
    2011, 31 (9):  1235. 
    doi: 10.3969/j.issn.1674-8115.2011.09.005

    Abstract ( 1602 )   PDF (5221KB) ( 1167 )  

    Cardiac anomaly is the most common developmental malformation and one of the leading causes of neonatal mortality and morbidity. As more women undergo prenatal diagnosis, the need for fetal echocardiography increases. Fetal echocardiography is a non-invasive method in detection of structural heart disease, cardiac arrhythmia and heart dysfunction. This paper not only discuses the indication, examination time, ultrasonic scanning plane, scanning technique, important advances and clinical application of fetal echocardiography, but also points out the limitation and prospects of research in this fields.

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    Original article
    Single nucleotide polymorphisms of TFAP-2B gene in children with patent ductus arteriosus
    CHEN Yi-wei, ZHAO Wu, LI Fen, et al
    2011, 31 (9):  1240. 
    doi: 10.3969/j.issn.1674-8115.2011.09.006

    Abstract ( 1719 )   PDF (7094KB) ( 1277 )  

    Objective To investigate the relationship between c.1-34G>A and c.539+62G>C polymorphisms of TFAP-2B gene and patent ductus arteriosus (PDA), and explore the possible molecular biological pathogenesis of PDA. Methods One hundred children confirmed with PDA were selected as study objectives (PDA group), and another 100 healthy children were served as control group. PCR was employed to amplify all the exons and flanking introns (50 bp at least) of TFAP2B gene, and direct forward and reverse sequencing of the PCR products was performed. The acquired sequences of TFAP-2B gene were aligned with those in GenBank (Accession Number: NG_008438) by BLAST program to detect the possible single nucleotide polymorphisms (SNP). Results Two novel SNP of TFAP-2B gene (c.1-34G>A and c.539+62G>C) were detected in PDA group and control group, which were not included in NCBI and GenBank. The frequencies of allele and genotype of c.1-34G>A in PDA group were significantly higher than those in control group (allele frequency: Z=-2.513, P=0.012; genotype frequency: Z=-2.680, P=0.007). There was no significant difference in the frequencies of allele and genotype of c.539+62G>C between two groups (allele frequency: Z=-0.332,P=0.74; genotype frequency: Z=-0.129,P=0.897). Conclusion c.1-34G>A polymorphism of TFAP-2B gene may be associated with PDA, which may be a risk factor for PDA.

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    Analysis of surgical management of transposition of great arteries with intact ventricular septum
    WANG Shun-min, XU Zhi-wei, LIU Jin-fen, et al
    2011, 31 (9):  1245. 
    doi: 10.3969/j.issn.1674-8115.2011.09.007

    Abstract ( 1642 )   PDF (5327KB) ( 1408 )  

    Objective To summarize the clinical experience in surgical management of transposition of the great arteries with intact ventricular septum (TGA/IVS). Methods One hundred and nineteen patients with TGA/IVS were divided into emergency operation group (n=61) and selected operation group (n=58), and patients were subjected to arterial switch operation (ASO)(emergency operation group, n=58; selected operation group, n=54, including 14 cases of second stage ASO), systemic-pulmonary shunt and pulmonary artery banding (emergency operation group, n=2; selected operation group, n=14) or Senning operation (emergency operation group, n=1; selected operation group, n=4). The operation and follow-up results were observed and compared between two groups, and univariate Logistic regression analysis was performed to determine the influencing factors for mortality early after operation. Results Twelve patients died in hospital after operation (10.1%), and the mortality of emergency operation group was higher than that of selected operation group, while there was no significant difference between two groups (14.8% vs 5.2%, P=0.08). Univariate Logistic regression analysis revealed that the risk factors for mortality early after operation were emergency ASO and preoperative left ventricle mass (LV Mass)≤50 g/m2 (P=0.05,P=0.00). Eighty-three survivors were followed up for 3 months to 4.5 years, during which no death occurred, and 1 patient underwent reoperation for supravalvular pulmonary stenosis. Conclusion Surgical management of TGA/IVS may yield good results, and application of balloon atrial septostomy and assisted circulation may further decrease the mortality after operation.

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    Primary arterial switch operation for D-transposition of the great arteries with intact ventricular septum in children older than 3 weeks
    XIE Feng, CHEN Hui-wen, LIU Jin-fen
    2011, 31 (9):  1250. 
    doi: 10.3969/j.issn.1674-8115.2011.09.008

    Abstract ( 7330 )   PDF (4379KB) ( 1297 )  

    Objective To assess the outcomes of primary arterial switch operation (ASO) in treatment of D-transposition of the great arteries (DTGA) with intact ventricular septum (IVS) in children older than 3 weeks, and explore the significance of helix ventricular myocardial band (HVMB) in the treatment of DTGA/IVS. Methods The clinical data of 54 children with DTGA/IVS aged between 3 weeks and 16 months (late ASO group) and 74 children with DTGA/IVS aged less than 3 weeks (early ASO group) were analysed. In late ASO group, children were subdivided into ventricular septal migration (VSM) group (n=20, ventricular septa were straight or skewed to the left) and ventricular septal normal (VSN) group (n=34, ventricular septa were normal in appearance). The surgical outcomes of ASO were evaluated. Results There was no significant difference in time of extracorporeal circulation, time of aortic clamping, time of ventilator application after operation, time of intensive care after operation, duration of hospitalization and mortality between late ASO group and early ASO group (P>0.05). There was no significant difference in mortality between VSM group and VSN group (10.0% vs 8.8%, P>0.05). Conclusion Primary ASO may be appropriate treatment for children with DTGA/IVS aged between 3 weeks and 16 months, and the normal appearance of ventricular septa plays an important role in the outcomes, which can be well explained by the theory of HVMB.

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    Clinical outcome of pediatric aortic valve repair
    ZHENG Jing-hao, XU Zhi-wei, LIU Jin-fen, et al
    2011, 31 (9):  1254. 
    doi: 10.3969/j.issn.1674-8115.2011.09.009

    Abstract ( 1657 )   PDF (4149KB) ( 1419 )  

    Objective To investigate the clinical application of aortic valve repair in pediatric aortic valve disease. Methods The clinical data of 83 children undergoing aortic valve repair were analysed. Patients aged between 4 months old and 11 years old, with the mean age of (3.6±5.0) years old. Patients were evaluated by ultrasound before operation, and single aortic insufficient was found in 24 patients, single aortic stenosis in 26 patients, and aortic insufficient combined with aortic stenosis in 33 patients. The repair techniques included commissurotomy (n=26), resuspension of commissures (n=27), pericardial patch cusp extension (n=15), raphe excision (n=12), cusp plication (n=6) and annuloplasty (n=2), and 50 patients required a combination of techniques. Results Patients were followed up for 3 months to 3 years. Two patients died, no patient was discharged with long-term treatment with anticoagulation drugs, and 2 patients underwent aortic valve replacement. Conclusion Aortic valve repair may yield favorable short-term and mid-term outcome in treatment of pediatric aortic valve disease, which can avoid reoperation and anticoagulation therapy. Aortic valve replacement can performed for reoperation during follow-up.

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    Mechanical circulatory support in treatment of children with refractory heart failure
    SHI Zhen-ying, ZHOU Yan-ping, XU Zhuo-ming, et al
    2011, 31 (9):  1258. 
    doi: 10.3969/j.issn.1674-8115.2011.09.010

    Abstract ( 1896 )   PDF (5190KB) ( 1252 )  

    Objective To summarize the intensive care experience of extracorporeal membrane oxygenation (ECMO) and left ventricular assist device (LVAD) in children with refractory heart failure. Methods Thirteen children having undergone operation for complicated congenital heart disease and 1 child with fulminant myocarditis received mechanical circulatory support due to refractory heart failure. There were 8 children in ECMO group and 6 children in LVAD group. The mean arterial pressure, central venous pressure, pressure of right atrium, pressure of left atrium, serum lactate concentration and oxygen saturation of mixed venous blood were monitored during mechanical circulatory support. The dosage of inotropic medicine was adjusted, the activated coagulation time was maintained between 150 s and 180 s, hematocrit between 30% and 35%, and platelet count >80 000/mm3. The mechanical circulatory support was weaned off when blood pressure was stable, pulse pressure was no lower than 20 mmHg, and left ventricular ejection fraction reached 50%. Results The mean time of mechanical circulatory support was (147±152) h in ECMO group and LVAD group. During the mechanical circulatory support, the blood pressure increased from (48.1±5.2) mmHg to (60.2±7.8) mmHg (P<0.05), while the serum lactate concentration decreased from (5.1±0.8) mmol/L to (3.6±0.5) mmol/L (P<0.05). The survival rate of weaning off was 57.1% (8/14), and the survival rate of hospital discharge was 42.9% (6/14). The major complication was severe bleeding in thoracic and abdominal cavity (63.7%). Four children had indifferent mind (28.6%), and 8 had multiple organ dysfunction (57.1%). During the follow up of 4 to 26 months, the left ventricular ejection fraction was no less than 50%, the cardiac function was class Ⅱ,the growth of children was significantly improved, and mild to moderate neural sequela was found in 2 children. Conclusion Mechanical circulatory support plays an effective role in the treatment of children having undergone operation for refractory heart failure. ECMO is more appropriate for neonates, infant and those with complicated congenital heart disease. Bleeding is the severe complication in mechanical circulatory support.

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    Hybrid approaches under direct vision in management of multiple muscular ventricular septal defects with associated cardiac malformations
    ZHANG Hai-bo, XU Zhi-wei, LIU Jin-fen, et al
    2011, 31 (9):  1263. 
    doi: 10.3969/j.issn.1674-8115.2011.09.011

    Abstract ( 1572 )   PDF (3502KB) ( 1236 )  

    Objective To observe the clinical outcomes of hybrid approach under direct vision in management of multiple muscular ventricular septal defects with associated cardiac malformations. Methods Forty patients with multiple muscular ventricular septal defects and associated cardiac malformations were enrolled, and hybrid approach under direct vision and cardiac malformation correction were performed with cardiopulmonary bypass. The results of operation and follow up were analyzed. Results Three patients died during operation, with the mortality of 7.5%. Pulmonary hypertension crisis occurred in 3 patients, and all were cured. No obvious residual shunt was observed in all patients. Patients were followed up for 6 months to 3 years, and no death occurred. Clinically insignificant residual shunt took place in 17 patients, and mild residual regurgitation was observed in 3 patients undergoing mitral valvuloplasty. Conclusion Hybrid approach under direct vision in management of multiple muscular ventricular septal defects, which can shorten the time of cardiopulmonary bypass and correct associated cardiac malformations at the same time, is convenient and safe, and may yield favorable mid-term and long-term outcomes.

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    Risk factors for early failure after systemic-to-pulmonary artery shunt in congenital heart disease
    XU Zhuo-ming, YANG Qi, GUO Lin-lin, et al
    2011, 31 (9):  1266. 
    doi: 10.3969/j.issn.1674-8115.2011.09.012

    Abstract ( 1899 )   PDF (3755KB) ( 1204 )  

    Objective To analyse the risk factors for the early failure of systemic-to-pulmonary artery shunt in cyanotic congenital heart disease (CHD). Methods The clinical data of 73 patients with cyanotic CHD undergoing systemic-to-pulmonary artery shunt were retrospectively analysed. The perioperative objective parameters were collected. Univariant analysis was performed with Chi-square test and multivariate analysis was carried out with Logistic regression analysis to seek the risk factors for early failure after systemic-to-pulmonary artery shunt. Results Fourteen patients experienced early failure. Chi-square test indicated that pulmonary atresia/intact ventricular septum, age no more than 60 d, long time of cardiopulmonary bypass, pulmonary artery enlargement and higher maximal inotrope score (ISmax>20) after surgery were associated with early failure. Logistic regression analysis revealed that pulmonary artery enlargement and ISmax>20 after surgery were independent risk factors for early failure. Conclusion For patients with cyanotic CHD having risk factors for early failure after systemic-to-pulmonary artery shunt, the management of intensive care after systemic-to-pulmonary artery shunt should be enhanced to reduce the incidence of early failure.

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    Analysis of risk factors for early mortality in patients with single ventricle series palliation for heterotaxy syndrome
    HUANG Ji-hong, SU Zhao-kang, WANG Liang-jun, et al
    2011, 31 (9):  1269. 
    doi: 10.3969/j.issn.1674-8115.2011.09.013

    Abstract ( 2029 )   PDF (4056KB) ( 1191 )  

    Objective To analyse the risk factors for early mortality in patients with heterotaxy syndrome undergoing single ventricle series palliation. Methods The clinical data of 61 consecutive patients with heterotaxy syndrome undergoing single ventricle palliation in Shanghai Children's Medical Center from January 2004 to January 2011 were retrospectively reviewed, and the risk factors for early mortality after operation were analysed. Single ventricle series palliation included Blalock shunt, pulmonary artery band, bidirectional cava-pulmonary shunt, modified Fontan and Kawashima procedure. Early mortality was recorded as a death event from the first surgical procedure to 30 d after Fontan operation. Results There were 8 early death events, with the early mortality of 13.1%. Among the 8 cases, one was left atrial isomerism, and the other 7 were right atrial isomerism; 2 occurred after neonatal operation, 1 occurred after bidirectional cavapulmonary shunt, and the other 5 occurred after modified Fontan. Multivariate Cox regression analysis revealed that neonatal operation (hazard ratio, 5.56; P=0.04), obstructed anomalous pulmonary venous drainage (hazard ratio, 18.21; P=0.02) and greater than moderate atrioventricular valve regurgitation (hazard ratio,12.31; P=0.03) were associated with early mortality after operation in heterotaxy syndrome. Conclusion The surgical outcome of left atrial isomerism may be better than that of right atrial isomerism. Neonatal operation, obstructed anomalous pulmonary venous drainage and greater than moderate atrioventricular valve regurgitation are risk factors for early mortality after operation in heterotaxy syndrome.

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    Clinical outcome and intensive care after Fontan operation
    LI Zhi-hao, XU Zhi-wei, ZHENG Jing-hao, et al
    2011, 31 (9):  1272. 
    doi: 10.3969/j.issn.1674-8115.2011.09.014

    Abstract ( 1575 )   PDF (4904KB) ( 1232 )  

    Objective To summarize the clinical outcome and hemodynamic feature after Fontan operation, and explore the main points of intensive care after operation. Methods Seventy-nine patients undergoing Fontan operation between July 2008 and July 2009 were collected. The main points of intensive care after operation and clinical outcome were summarized through analysis of the hemodynamic feature and course of intensive care. Results Five patients died early after operation, and the mortality was 6.33%. There was no death in stage 1 operation, the mortality of stage 2 operation was 9.3%, and the mortality of stage 3 operation was 14.3%. The echocardiogram demonstrated the generalized reduction in blood flow in inferior vena cava after operation, and right to left shunt in fenestration was observed on the first day after operation in all cases. Early withdrawl of mechanical ventilation led to an optimal recovery in hemodynamics. There was a higher incidence of organ dysfunction after operation. Conclusion Hemodynamic assessment before operation is important for the clinical outcome of Fontan operation. The slow flow in inferior vena cava and the dominant right to left shunt in fenestration after operation may affect the perfusion of organs, and the early withdrawl of mechanical ventilation is recommended. The close relationship between heart and lung after Fontan operation demands the management of pulmonary complications without delay. The main points to improve the low cardiac output are volume resuscitation, suitable inotropic support and pulmonary resistance reduction. The unique effect of milrinone in the treatment after Fontan operation is emphasized.

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    Effect of tracheobronchomalacia on early recovery after surgical repair for congestive congenital heart disease
    ZHU Li-min, XU Zhuo-ming, LIU Li-ping, et al
    2011, 31 (9):  1277. 
    doi: 10.3969/j.issn.1674-8115.2011.09.015

    Abstract ( 1932 )   PDF (5191KB) ( 1285 )  

    Objective To investigate the effect of tracheobronchomalacia (TBM) on early recovery after surgical repair for different types of congestive congenital heart disease (CHD). Methods The clinical data of all the patients with congestive CHD hospitalized in intensive care unit of Department of Cardiovascular and Thoracic Surgery, Shanghai Children's Medical Center affiliated to Shanghai Jiaotong University School of Medicine between January 2007 and December 2010 were retrospectively analysed. Patients of each type of congestive CHD were divided into TBM group and non-TBM group according to the findings of bronchofiberscopy, and the clinical data and outcomes were compared. Results There were 237 cases of TBM diagnosed by bronchofiberscopy in 5 061 cases of congestive CHD, with the incidence of 4.7%. Coarctation of the aorta with ventricular septal defect, persistent truncus arteriosus and interruption of aortic arch with ventricular septal defect had the higher incidences of TBM, which were 34.68%, 29.17% and 28.00%, respectively. In patients with atrioventricular septal defect, ventricular septal defect and atrial septal defect, the age and body weight in TBM group were significantly lower than those in non-TBM group (P<0.05). In patients with transposition of the great arteries, the age and body weight in TBM group were significantly higher than those in non-TBM group (P<0.05). There was no significant difference in age and body weight between TBM group and non-TBM group in patients with the other types of CHD (P>0.05). Except for the patients with interruption of aortic arch with ventricular septal defect, those in TBM group of children with the other types of CHD had prolonged time of mechanical ventilation and/or duration of intensive care unit stay (P<0.05). Conclusion TBM may lead to prolonged time of mechanical ventilation and duration of ICU stay in patients with congestive CHD, especially in young infants with low body weight. Evaluation of the airway conditions before surgery and design of the postoperative mechanical ventilation management are important.

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    Outcome of aortic translocation procedure in treatment of complete transposition of great arteries with ventricular septal defect and pulmonary stenosis
    DU Xin-wei, XU Zhi-wei
    2011, 31 (9):  1283. 
    doi: 10.3969/j.issn.1674-8115.2011.09.016

    Abstract ( 1437 )   PDF (4730KB) ( 1308 )  

    Objective To investigate the outcome of aortic translocation procedure in the treatment of complete transposition of the great arteries with ventricular septal defect and pulmonary stenosis. Methods Twenty-one patients with complete transposition of the great arteries with ventricular septal defect and pulmonary stenosis underwent aortic translocation procedure between January 2005 and June 2010. Inlet ventricular septal defects were found in 4 patients, and straddling tricuspid valves were found in 3 patients. The operation and follow up results were retrospectively analysed, and the outcome was evaluated. Results There was 1 case of in-hospital death. Among the other 20 patients, there was 1 case of low cardiac output syndrome, 7 cases of acute renal failure, 1 case of acute liver injury and 2 cases of pulmonary infection after operation, and all were cured and discharged. Patients were followed up for 8 to 61 months, there was no death and no left ventricular outlet obstruction or ventricular arrhythmia during the follow up, and cardiac function recovered in all patients. Conclusion Aortic translocation procedure may yield favorable long-term outcome in treatment of complete transposition of the great arteries with ventricular septal defect and pulmonary stenosis. However, the patients have to pull through the early stage after operation and require intensive care for cardiac function.

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    Therapeutic effect of vardenafil on pulmonary hypertension after operation for congenital heart disease
    GONG Xiao-lei, ZHU Li-min, CAI Xiao-man, et al
    2011, 31 (9):  1287. 
    doi: 10.3969/j.issn.1674-8115.2011.09.017

    Abstract ( 1606 )   PDF (4533KB) ( 1398 )  

    Objective To assess the application of phosphodiesterase 5 inhibitor vardenafil to pulmonary hypertension after operation for congenital heart disease. Methods Twelve children with pulmonary hypertension after bi-ventricular repair for congenital heart disease were treated with vardenafil. Routine follow up was conducted after medication, and therapeutic effect and adverse effects were observed. Results The pulmonary hypertension was (71±19) mmHg (1 mmHg=0.133 kPa) before treatment with vardenafil, those were (48±23) mmHg and (34±13) mmHg 3 months and 6 months after treatment with vardenafil respectively, and there were significant differences between that before treatment with vardenafil and those 3 months and 6 months after treatment with vardenafil (P<0.05). The New York Heart Association Functional Class (NYHAFC) significantly improved after treatment with vardenafil (P<0.01). The 6 min walking distance (6MWD) of 10 patients 3 months after treatment with vardenafil was significantly longer than that before treatment with vardenafil [(413±58) m vs (382±68) m, P<0.01]. The major side effect of vardenafil was facial flushing, and the incidence was 33.33%(4/12). One patient with prolonged Q-T interval on electrocardiogram 3 months after treatment with vardenafil stopped medication. Conclusion Vardenafil can decrease pulmonary hypertension after bi-ventricular repair for congenital heart disease, increase exercise capacity, and improve NYHAFC of children. There is no severe side effects after treatment with vardenafil, while the changes of Q-T interval on electrocardiogram should be monitored during medication.

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    Hybrid approaches for pulmonary atresia with intact ventricular septum
    DONG Wei, ZHANG Hai-bo
    2011, 31 (9):  1291. 
    doi: 10.3969/j.issn.1674-8115.2011.09.018

    Abstract ( 1600 )   PDF (4757KB) ( 1217 )  

    Objective To investigate the outcome of hybrid approaches of balloon valvuloplasty via pulmonary valve without cardiopulmonary bypass for pulmonary atresia with intact ventricular septum in neonates. Methods Eleven patients undergoing hybrid approaches of balloon valvuloplasty via pulmonary valve for pulmonary atresia with intact ventricular septum were selected, and the clinical features and surgical procedures were recorded. Results Among the 11 patients, there were 9 with pulmonary atresia with intact ventricular septum and 2 with severe pulmonary stenosis. The right ventricles were normally developed, and the Z values of tricuspid valves were >-2. All patients underwent balloon valvuloplasty via pulmonary valve without cardiopulmonary bypass, and there was no death during operation. The mean blood oxygen saturation after operation was (90±4)%, and there was no complication related to balloon valvuloplasty. Low cardiac output syndrome occurred in 2 patients, and there was no in-hospital death. Patients were followed up for an average of (8±3) months, all patients had mild to moderate pulmonary stenosis, and 1 needed a right ventricular outflow tract patch for pulmonary stenosis after operation. Conclusion Pulmonary valvuloplasty with hybrid technique is effective in management of pulmonary atresia with intact ventricular septum in neonates, which may provide adequate pulmonary blood flow and promote further growth of tricuspid valve and right ventricular cavity with less trauma and more safety.

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    Mitral valvuloplasty for congenital mitral valve regurgitation in children
    PENG Yong-xuan, LU Ya-nan, DING Wen-xiang, et al
    2011, 31 (9):  1295. 
    doi: 10.3969/j.issn.1674-8115.2011.09.019

    Abstract ( 1895 )   PDF (4354KB) ( 1132 )  

    Objective To evaluate the application of mitral valvuloplasty to congenital mitral valve regurgitation in children. Methods The surgical indications, procedures, therapeutic effects and follow-up results of 78 children with mitral valve regurgitation undergoing mitral valvuloplasty were analysed. Results The average duration of follow up was 12.6 months (0.5 month to 73 months). Three patients died after operation during hospitalization. Postoperative complications occurred in 15 patients (19.2%). A second operation was performed in 4 patients, including mitral valve replacement (n=3) and redo mitral valvuloplasty (n=1). One patient was re-hospitalised due to heart failure. During the follow up, grades of mitral valve regurgitation were significantly decreased compared to those before operation (P<0.05). Conclusion Mitral valvuloplasty in children may lead to favorable early outcomes, adapt to children's growth, and effectively delay or avoid mitral valve replacement.

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    Prenatal magnetic resonance imaging in evaluation of fetal cardiac malposition
    DONG Su-zhen, ZHU Ming, LI Fen, et al
    2011, 31 (9):  1299. 
    doi: 10.3969/j.issn.1674-8115.2011.09.020

    Abstract ( 1733 )   PDF (6778KB) ( 1143 )  

    Objective To explore the diagnostic value of magnetic resonance imaging (MRI) on fetal cardiac malposition. Methods MRI examinations were performed 24 to 48 h after routine ultrasound examinations on 57 pregnant women with gestation of 20 to 36 weeks. The imaging protocols included 2 dimension fast imaging employing steady-state acquisition (2D FIESTA), single-shot fast spin echo (SSFSE), T1-weighted fast inversion recovery motion insensitive (FIRM) and dynamic FIESTA sequences in the axial, frontal and sagittal planes relative to the fetal brain, thorax, abdomen, especially lung and heart. Prenatal ultrasound and MRI findings were compared with postnatal diagnoses (n=49) or autopsy (n=8). Postnatal evaluation included a variety of imaging and surgery. Results There were 5 cases of primary fetal cardiac malposition (dextrocardia) and 52 cases of secondary fetal cardiac malposition. The causes of secondary cardiac malposition included right pulmonary hypoplasia (n=7), congenital diaphragmatic hernia (CDH, n=18), congenital cystic adenomatoid malformation (CCAM, n=24), bronchopulmonary sequestration (BPS, n=2) and mediastinal mass (n=1). Conclusion Prenatal MRI is effective in the assessment of fetal cardiac malposition and its causes with the integrated application of sequences. The same section of FIESTA sequence can reveal the abnormal position of fetal heart and other chest lesions causing changes in fetal heart position. Dynamic FIESTA sequence can demonstrate obvious abnormal cardiac blood flow. Both SSFSE and FIRM sequences can well display other chest abnormalities causing changes in fetal heart position.

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    Comparison of imaging diagnosis of peripheral pulmonary vascular anomaly of acyanotic congenital heart disease
    WU Hao, ZHONG Yu-min, GAO Wei, et al
    2011, 31 (9):  1303. 
    doi: 10.3969/j.issn.1674-8115.2011.09.021

    Abstract ( 1555 )   PDF (5815KB) ( 1303 )  

    Objective To investigate the application of noninvasive imaging diagnosis of peripheral pulmonary vascular anomaly of acyanotic congenital heart disease (CHD). Methods Computed tomography angiography (CTA) and/or magnetic resonance imaging angiography(MRA) were performed on 200 patients with acyanotic CHD and peripheral pulmonary vascular stenosis (36 of whom had postoperative residual peripheral pulmonary vascular stenosis) before operation or angiocardiography (ACG), the diameters of stenotic segment of peripheral pulmonary vessels were measured by CTA and MRA, and were compared with those obtained by ACG or intraoperative direct vision through paired-samples T test. Results ACG, CTA and MRA could clearly demonstrate the morphology of peripheral pulmonary vessels and their branches. There was no significant difference between the diameters of stenotic segment of peripheral pulmonary vessels measured by CTA and MRA and those obtained by ACG or intraoperative direct vision. Conclusion CTA and MRA are favorable noninvasive imaging methods in evaluation of morphology of peripheral pulmonary vessels, and can replace the invasive ACG.

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    Application of magnetic resonance imaging in follow-up after surgery for tetralogy of Fallot
    SUN Ai-min, ZHONG Yu-min, GAO Wei, et al
    2011, 31 (9):  1307. 
    doi: 10.3969/j.issn.1674-8115.2011.09.022

    Abstract ( 1623 )   PDF (6020KB) ( 1144 )  

    Objective To investigate the application of magnetic resonance imaging (MRI) in the follow-up after surgery for tetralogy of Fallot (TOF). Methods Seventy-one patients were examined with MRI during follow up after surgery for TOF, and the scanning sequences included  fast imaging employing steady-state acquisition (FIESTA), phase-contrast magnetic resonance imaging (PCMR) and contrast enhanced magnetic resonance angiography (CE-MRA). Results Branch pulmonary artery stenosis was detected by CE-MRA in 44 of 71 (62.0%) patients, including left pulmonary artery stenosis (n=29, 40.8%), right pulmonary artery stenosis (n=4, 5.6%) and both left and right pulmonary artery stenosis (n=11, 15.5%). With FIESTA sequence, right ventricular enddiastolic volume was measured at (115.28±15.18) mL/m2. Varied amount of pulmonary regurgitation (42.12%±16.30%) occurred in all 38 cases with PCMR. Meanwhile, serious pulmonary regurgitation was observed in 14 cases (36.8%), with pulmonary artery regurgitant fraction >40%. In patients without branch pulmonary artery stenosis, regurgitant fraction of the left pulmonary artery (57.70%±21.99%) was significantly higher than that of the right pulmonary artery (30.32%±13.44%)(P<0.01). Delayed onset of the tricuspid valve flow was observed by PCMR in 18 (54.5%) of 33 patients. However, there was no significant difference in the pulmonary artery regurgitant fraction, right ventricular ejection fraction and right ventricular end-diastolic volume index  between patients with and without delayed onset of the tricuspid valve flow (P>0.05). Conclusion Left pulmonary stenosis, pulmonary regurgitation and right ventricular enlargement are common complications after surgery for TOF. MRI can provide adequate information on residual anatomical problems and functional evaluation, which makes it ideally suited to the evaluation of  patients after surgery for TOF.

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    Multislice CT in diagnosis of vascular rings with tracheal stenosis
    WANG Qian, ZHONG Yu-min, SUN Ai-min, et al
    2011, 31 (9):  1312. 
    doi: 10.3969/j.issn.1674-8115.2011.09.023

    Abstract ( 1430 )   PDF (5121KB) ( 1684 )  

    Objective To investigate the value of multislice CT in the diagnosis of tracheal stenosis caused by vascular ring malformation. Methods The imaging data of multislice CT of 99 cases of vascular ring malformation were retrospectively analysed. Maximum and minimum density project reconstructions were performed to observe the abnormal blood vessels and presence of tracheal stenosis. Results Forty-six of 52 cases of pulmonary sling were associated with tracheal stenosis, and it was illustrated by CT that the left pulmonary artery derived from the right pulmonary artery, extended backward and leftward between trachea and esophagus, encircled and compressed trachea to cause tracheal stenosis. Eighteen of 22 cases of double aortic arch were associated with tracheal stenosis, and it was illustrated by CT that the ascending aorta branched into left aortic arch and right aortic arch in front of trachea, merged in back of trachea after crossing left bronchus and right bronchus respectively and formed the vascular ring. One case of right aortic arch with persistent left ligament was associated with tracheal stenosis, and it was illustrated by CT that the aortic arch located right to the trachea, the arterial ductus derived from the proximal end of descending aorta, extending leftward in back of esophagus, and joined the origin of the left pulmonary artery to form the vascular ring. Eighteen of 24 cases of right aortic arch with aberrant left subclavian artery and left arterial ductus were associated with tracheal stenosis, and it was illustrated by CT that right aortic arch, aberrant left subclavian artery and left arterial ductus encircled the trachea and esophagus to form the vascular ring. Conclusion Vascular ring malformation is usually accompanied by tracheal stenosis. Multislice CT can well demonstrate the anatomy of vascular anomalies, and may have a precise evaluation of tracheal stenosis.

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    Effects of sevoflurane preconditioning and postconditioning on myocardial reperfusion injury under cardiopulmonary bypass in infants
    SUN Ying, ZHU Ming, ZHANG Jan-wei, et al
    2011, 31 (9):  1316. 
    doi: 10.3969/j.issn.1674-8115.2011.09.024

    Abstract ( 1791 )   PDF (4206KB) ( 1242 )  

    Objective To investigate the effects of sevoflurane preconditioning and postconditioning on myocardial reperfusion injury under cardiopulmonary bypass in infants undergoing surgery for congenital heart disease. Methods Sixty children undergoing surgery for ventricular septal defect were randomly divided into control group (no inhalation anesthetics during the surgery), preconditioning group (inhalation of 1.5 MAC sevoflurane for 20 min before aortic cross clamping), postconditioning group (inhalation of 1.5 MAC sevoflurane for 20 min after aortic cross unclamping) and preconditioning+postconditioning group (inhalation of 1.5 MAC sevoflurane for 20 min before and after aortic cross clamping respectively), with 15 patients in each group. The time of aortic cross clamping, time of cardiopulmonary bypass, time of operation, time of mechanical ventilation, duration of stay in cardiac intensive care unit (CICU) and duration of hospital stay were recorded and compared. The mass concentrations of myocardial injury markers of troponin I (cTn-I), myoglobin (Mb) and creatine kinase isoenzyme (CK-MB) were determined after anesthesia induction (T0), before cardiopulmonary bypass (T1), at the end of cardiopulmonary bypass (T2), and 1 h, 6 h, 12 h and 24 h after cardiopulmonary bypass (T3, T4, T5 and T6 respectively). Results There was no significant difference in time of aortic cross clamping, time of cardiopulmonary bypass, time of operation, time of mechanical ventilation, duration of stay in CICU and duration of hospital stay among groups (P>0.05). The plasma mass concentrations of cTnⅠ, Mb and CK-MB at the time points of T2 to T6 were significantly higher than those at the time point of T0 in each group. The plasma mass concentrations of cTnⅠ, Mb and CK-MB at the time points of T3 to T5 in preconditioning group, postconditioning group and preconditioning+postconditioning group were significantly lower than those in control group (P<0.05). There was no significant difference in the plasma mass concentrations of cTnⅠ, Mb and CK-MB at each time point among preconditioning group, postconditioning group and preconditioning+postconditioning group (P>0.05). Conclusion Both sevoflurane preconditioning and postconditioning can relieve myocardial reperfusion injury under cardiopulmonary bypass in infants undergoing surgery for congenital heart disease, while the combination of them may not bring additional benefit.

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    Cardiopulmonary bypass related factors associated with early extubation after surgery for congenital heart disease under fast-track cardiac anesthesia in children
    HUANG Yue, ZHANG Ma-zhong, SONG Yan-yan, et al
    2011, 31 (9):  1320. 
    doi: 10.3969/j.issn.1674-8115.2011.09.025

    Abstract ( 1881 )   PDF (5575KB) ( 1789 )  

    Objective To analyse the perioperative data of patients undergoing surgery with cardiopulmonary bypass (CPB) under fast-track cardiac anesthesia (FTCA), establish the cutoff value of early extubation in FTCA standards, and explore the CPB related factors associated with FTCA. Methods The data of 2 859 children undergoing surgery for congenital heart disease managed with FTCA strategy were retrospectively analysed. Cluster analysis was performed with logarithmic transformation of the time of mechanical ventilation after surgery to establish pediatric FTCA standards of cutoff value of early extubation after operation. The related factors of FTCA were analysed by chi-square test and stepwise multiple Cox regression analysis. Results Cluster analysis of time of mechanical ventilation after operation revealed that 12 h after operation was the cutoff value for early extubation after operation. There were 54.56% of patients with time of extubation <12 h after operation (early extubation group), and there were 45.44% of patients with time of extubation ≥12 h after operation (non-early extubation group). The early extubation rates after operation were 83.1%, 66.3%, 42.5%, 28.7% and 26.8% in different time of CPB (≤30 min, 31-60 min, 61-90 min, 91-120 min and >120 min) groups respectively, and there were significant differences among groups (P<0.01). The early extubation rates after operation were 55.6%, 71.8%, 46.4%, 27.6% and 20.9% in different time of aortic cross-clamping (0 min, 1-30 min, 31-60 min, 61-90 min and >90 min)groups, and there were significant differences among groups (P<0.01). The early extubation rates after operation were 66.9%, 49.6%, 29.0% and 21.5% in different temperatures of CPB (room temperature, mild hypothermia, moderate hypothermia and profound hypothermia) groups, and there were significant differences among groups (P<0.01). Stepwise multiple Cox regression analysis indicated that longer time of CPB resulted in lower rate of early extubation after operation. The rate of early extubation after operation in time of aortic cross-clamping of 1-30 min group was higher than that in control group (0 min)(P<0.05), there was no significant difference in the rates of early extubation after operation between time of aortic cross-clamping of 31-60 min and 61-90 min groups and control group (P>0.05), and the rates of early extubation after operation in time of aortic cross-clamping >90 min group was lower than that in control group. Lower temperature of CPB resulted in lower rate of early extubation after operation. Conclusion Twelve hours after operation was defined as the cutoff value of early extubation in FTCA standard. Time of CPB, time of aortic crossclamping and temperature of CPB are CPB related factors for extubation after operation.

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    Review
    Research progress of computational fluid dynamics in surgical approach simulation for congenital heart disease
    LIU Yu-jie, ZHENG Jing-hao
    2011, 31 (9):  1325. 
    doi: 10.3969/j.issn.1674-8115.2011.09.026

    Abstract ( 1511 )   PDF (4147KB) ( 1266 )  

    Computational fluid dynamics is an intuitive and visualised method, which facilitates the simulation of cardiovascular system under physiological and pathological states with multidisciplinary intergration. Computational fluid dynamics can work in estimation of hemodynamics preoperation, evaluation of blood flow of structure region postoperation and surgical approach simulation. The research progress of computational fluid dynamics in surgical approach simulation for congenital heart disease is reviewed in this paper.

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    Clinical application of heart ischemic preconditioning and postconditioning
    XU Yuan-lin, WANG Wei
    2011, 31 (9):  1328. 
    doi: 10.3969/j.issn.1674-8115.2011.09.027

    Abstract ( 1219 )   PDF (4012KB) ( 1146 )  

    Heart ischemic preconditioning and postconditioning may have a protective effect against ischemia-reperfusion injury. Heart ischemic preconditioning can improve myocardial tolerance to ischemia, reduce myocardial infarct size, protect endothelial function, and is associated with significant reduction in ventricular arrhythmias, inotrope requirement and intensive care unit stay. Ischemic postconditioning may attenuate cardiomyocyte apoptosis and improve the recovery of left ventricular systolic function. This article focuses on the clinical application, main mechanism and influencing factors of heart ischemic preconditioning and postconditioning.

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    Research progress of pre-operative brain injury in children with congenital heart disease
    TANG Jia-zhong, WANG Wei
    2011, 31 (9):  1332. 
    doi: 10.3969/j.issn.1674-8115.2011.09.028

    Abstract ( 1611 )   PDF (3290KB) ( 1029 )  

    Brain injury may occur in children after surgery for congenital heart disease, and brain injury was considered to be associated with surgical procedures and cardiopulmonary bypass. However, it has been reported that brain injury may exist in children with congenital heart disease before surgery. This paper systematically summarizes the basic types of brain injury and epidemiology and possible pathogenesis of brain injury before surgery in children with congenital heart disease.

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    Research progress of anesthetic management of single-ventricle children
    ZHANG Rui-dong, ZHANG Ma-zhong, CHEN Xi-ming, et al
    2011, 31 (9):  1335. 
    doi: 10.3969/j.issn.1674-8115.2011.09.029

    Abstract ( 1431 )   PDF (4387KB) ( 1289 )  

    Single ventricle physiology occurs when one of the ventricles is hypoplastic or absent. Therefore, blood to the pulmonary and systemic vascular beds is pumped by one ventricle. The development of a number of operations, combined with a greater understanding of the physiologic requirements for success after single ventricle reconstruction has resulted in dramatic improvement in outcomes. This review highlights the anatomy and physiology of single-ventricle patients before, during and after surgical palliation. Besides, the anesthetic challenges presented by single-ventricle patients are also reviewed.

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    Application of magnetic resonance imaging in diagnosis of congenital heart disease
    WU Hao, ZHONG Yu-min
    2011, 31 (9):  1339. 
    doi: 10.3969/j.issn.1674-8115.2011.09.030

    Abstract ( 1691 )   PDF (4305KB) ( 1197 )  

    In recent years, with the rapid development of medical imaging in techniques and equipment, more imaging diagnostic methods have been available to the diagnosis of congenital heart disease, especially complicated congenital heart disease. The commonly used imaging diagnostic methods in clinics are digital subtraction angiography (DSA), echocardiography (Echo), multi-slice spiral CT (MSCT) and magnetic resonance imaging (MRI). MRI can evaluate both anatomy and function of congenital heart disease, and has been extensively applied in clinics. This review introduces the application of MRI in the diagnosis of congenital heart disease.

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    Brief original article
    Implantation of permanent pacemakers for children with congenital complete atrioventricular block and atrial septal defect
    ZHAO Peng-jun, LI Fen, LI Yun, et al
    2011, 31 (9):  1343. 
    doi: 10.3969/j.issn.1674-8115.2011.09.031

    Abstract ( 1951 )   PDF (5646KB) ( 1349 )  

    Objective To evaluate the treatment method of children with congenital complete atrioventricular block (CCAVB) and atrial septal defect (ASD), and discuss the attention of permanent pacemaker implantation. Methods Based on age and body weight of 3 children with CCAVB and ASD, 1 was implanted with an epicardial pacemaker after repairing ASD by surgical procedure, and 2 were implanted with permanent endocardial pacemakers after interventional procedures for ASD. The model of pacing was VVI for all patients. Results Endocardial pacemaker was attempted to implant in one patient after repairing ASD, while ended up with epicardial pacemaker implantation due to difficulty in lead fastening with small vein. The endocardial pacing was normal during the follow-up. However, the epicardial pacing failed two years after follow up due to lead shifting, and was reset after a new lead installation. No abnormality in cardiac function was found by echocardiography during follow up. Conclusion ASD should first be repaired through interventional or surgical procedures in patients with CCAVB and ASD meeting the indications for permanent pacemaker implantation. Epicardial pacemakers can be implanted in young infants with light weight, and endocardial pacemakers can be implanted in old children after interventional procedures for ASD. There is no significant difference in pacemaker parameters between these two pacing models. More attention should be paid to the lead fastening of epicardial pacing and the room between lead and occluder of endocardial pacing to avoid the lead abrasion.

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    Effect of afterload pressure on hemolytic blood damage in Sarns2000 centrifugal pump
    HAN Lu, WANG Wei, YU Xiao-qing, et al
    2011, 31 (9):  1347. 
    doi: 10.3969/j.issn.1674-8115.2011.09.032

    Abstract ( 1341 )   PDF (8125KB) ( 1007 )  

    Objective To investigate the effect of afterload pressure on hemolytic blood damage in centrifugal pump. Methods The differences between velocity, pressure and surface shear force of the internal flow of Sarns2000 centrifugal pump with afterload pressure and those without afterload pressure were obtained by computational fluid dynamics(CFD). Results The velocity and flow of pump deceased when the rotational speed was 1 400 r/min with afterload pressure. The hemolytic blood damage increased with the pressure increase in the pump. However, the area whose surface shear force was greater than 150 Pa was less than 0.000032%, which had a good performance of hemolysis. Conclusion The afterload pressure would enhance the possibility of hemolysis in Sarns2000 centrifugal pump, while the surface shear force has a good performance of hemolysis.

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    Clinical experience
    Application of autologous pericardial patch in repairing simple ventricular septal defect of infants
    GAO Bo-tao, ZHENG Jing-hao, LIU Yu-jie, et al
    2011, 31 (9):  1352. 
    doi: 10.3969/j.issn.1674-8115.2011.09.033

    Abstract ( 2174 )   PDF (3374KB) ( 1148 )  

    Objective To investigate the outcomes of autologous pericardial patch treated by glutaraldehyde in repairing simple ventricular septal defect of infants. Methods Four hundred and three infants with ventricular septal defect were selected, and the ventricular septal defect was repaired with autologous pericardial patch treated by glutaraldehyde. Results No patient experienced hemolysis, infection, three-degree atrioventricular block and aneurysmal dilation after operation. Residual shunt occurred in 29 patients. Patients were followed up for 1.5 months to 2 years, the residual shunt disappeared in 26 patients, and that of the other 3 patients was not healed, while none needed a second operation. There was no significant difference in the rates of residual shunt among patients with different ages and different types of ventricular septal defect (P>0.05). Conclusion Autologous pericardial patch treated by glutaraldehyde is a good material for repairing simple ventricular septal defect of infants.

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    Control of unplanned endotracheal extubation with Healthcare Failure Mode and Effect Analysis
    GUAN Yong-mei, SHEN Nan-ping, HE Ping-ping
    2011, 31 (9):  1355. 
    doi: 10.3969/j.issn.1674-8115.2011.09.034

    Abstract ( 1461 )   PDF (2833KB) ( 1334 )  

    Objective To improve the nursing procedure of endotracheal intubation for control of unplanned extubation with healthcare failure mode and effect analysis (HFMEA). Methods HFMEA was adopted to explore the main causes for unplanned endotracheal extubation in Cardiac Center, Shanghai Children's Medical Center affiliated to Shanghai Jiaotong University School of Medicine, and modified nursing procedure of endotracheal intubation was designed. Results After implementation of the modified nursing procedure, the unplanned endotracheal extubation rate decreased from 0.188 in 2009 to 0.113 in 2010. Conclusion Through improvement of nursing procedure of endotracheal intubation and education on medical staff on prevention of unplanned extubation with HFMEA, unplanned endotracheal extubation rate can be effectively controlled.

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    Case report
    Three cases report of rare complications after Fontan operation
    PAN Yan-jun, ZHANG Hai-bo, ZHU Hong-bin, et al
    2011, 31 (9):  1358. 
    doi: 10.3969/j.issn.1674-8115.2011.09.035

    Abstract ( 1486 )   PDF (2948KB) ( 1217 )  

    Three cases of rare complications after Fontan operation were retrospectively analysed. Two cases experienced complication of protein-losing enteropathy, among whom one was diagnosed as asplenia with single ventricle and pulmonary stenosis, and the other was diagnosed as functional single ventricle with pulmonary hypertension. The other case had complication of plastic bronchitis, who was diagnosed as congenital corrected transposition of the great arteries with ventricular septal defect and pulmonary stenosis. Time intervals between Fontan operation and occurrence of complications were 3 weeks, 3 months, and 5 months respectively. One patient died after operation, and 1 patient lost in follow up. The increased systemic venous pressure, low cardiac output and high pulmonary resistance may be possible mechanisms of protein-losing enteropathy and plastic bronchitis.

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