Clinical Observation On Different Treatment Methods Of The Major Aorta-pulmonary Collateral Arteries In The Perioperative Period Of Tetralogy Fallot In Children

BackgroundThe serious tetralogy of fallot（TOF）is associated with major aorta-pulmonary collateral arteries（MAPCAS）due to lack or lack of intracardiac pulmonary blood supply.Because the MAPCAs will bring a series of adverse effects such as pulmonary blood stasis and low cardiac output syndrome after the radical operation of tetralogy of Fallot,it is currently advocated to treat MAPCAs before radical operation.Treatment methods include surgical ligation or（and）medical interventional embolization,but this will lead to further reduction of pulmonary blood,even lung infarction,irreversible damage or even death.At the same time,there was little research on the relationship between the MAPCAs and pulmonary hemorrhage.ObjectiveTo understand the relationship between the MAPCAs and pulmonary hemorrhage after the radical operation of tetralogy of Fallot.In order to reduce the mortality of radical surgery for tetralogy of Fallot with MAPCAs,analysis of the effect of no treatment of MAPCAs before the radical surgery on pulmonary hemorrhage after the endothelial treatment of TOF,a new programme for the treatment of Fallot with MAPCAs was discussed。MethodsChildren with MAPCAs（MAPCAs internal diameter of≥1mm）were selected from June 2015 to June 2018 in Chengdu Cardiovascular Hospital.91 cases were enrolled,including 59 males and 32 females,with an age of 3.79±1.77 years.According to the different treatment methods of the MAPCAs before the radical operation of tetralogy of Fallot divided into treatment group and non-treatment group.Treatment group:treatment of MAPCAs before radical surgery for tetralogy of Fallot;Non-treatment group:no treatment of MAPCAs before the radical surgery of TOF,the use of PEEP and other methods to prevent and treat pulmonary hemorrhage after the radical surgery of TOF,such as invalid and then consider the treatment of the MAPCAs.In order to understand the relationship between no treatment the MAPCAs and pulmonary hemorrhage after the radical surgery of TOF,the non-treatment group was divided into pulmonary hemorrhage group and non-pulmonary hemorrhage group according to pulmonary hemorrhage,and the massive pulmonary hemorrhage group（if the amount of hemorrhage with in 24 hours was≥8ml/kg or≥200 ml,it was defined as massive pulmonary hemorrhage group）and the non-massive pulmonary hemorrhage group.There were 36 patients in the treatment group,26 males and 10 females,55 cases in non-treatment group,33 cases of men and 22 cases of women.Statistic follow data:（1）Patient age,the origin,the number and inner diameter of the MAPCAs,including the maximum internal and average internal diameter of the MAPCAs;（2）4h,8h,12h,16h,20h,24h Fi O₂after radical surgery of tetralogy of Fallot,1/2 h,4 h,8 h,12,h6 h,20 h,24 h Pa2/Fi O₂after radical surgery of tetralogy of Fallot;（3）Ventilation time,ICU hospitalization time;（4）Hospitalization costs;（5）postoperative complications and prognosis:pulmonary hemorrhage,hypoxemia（Pa O₂/Fi O₂<300mm Hg）,low cardiac output syndrome hypocardiac discharge.Results（1）There were 18 cases（32.73%）pulmonary hemorrhag and 5 cases（9.09%）without treatment of the MAPCAs before the radical surgery of tetralogy of Fallot.2 cases（3.6%）were needed to treat the MAPCAs after radical surgery of tetralogy of Fallot.1mm≤the maximum internal diameter of the MAPCAs<2mm,there are 0 cases of pulmonary hemorrhage,0 cases of massive pulmonary hemorrhage;2mm≤the maximum internal diameter of the MAPCAs<3mm,there are 6 cases of pulmonary hemorrhage,1cases of massive pulmonary hemorrhage;the maximum internal diameter of the MAPCAs≥3mm,and there are 12 cases of pulmonary hemorrhage,4 cases of massive pulmonary hemorrhage.The pulmonary hemorrhage（P<0.05）and the massive pulmonary hemorrhage（P<0.05）in the three groups is statistically significant.The number（branch）,the maximum internal diameter（mm）,the average internal diameter（mm）of the MAPCAs non-pulmonary hemorrhage group VS pulmonary hemorrhage group is3.76±0.83VS5.33±1.28（P<0.05）,2.10±0.25VS3.32±0.35（P<0.05）,1.72±0.21VS2.39±0.30（P<0.05）,There is statistical significance between the two groups.The number（branch）,the maximum internal diameter（mm）,the average internal diameter（mm）of the MAPCAs,non-massive pulmonary hemorrhage group VS massive pulmonary hemorrhage group is4.06±1.03VS6.04±1.14（P<0.05）,2.40±0.59VS3.44±0.31（P<0.05）,1.87±0.47VS2.62±0.34（P<0.05）,There is statistical significance between the two group.（2）18 cases of pulmonary hemorrhage（32.73%）in the non-treatment group,higher than 4 cases of pulmonary hemorrhage in the treatment group（11.11%）,and statistical significance between the two groups（P<0.05）.5 cases of massive pulmonary hemorrhage in the non-treatment group,3 cases of massive pulmonary hemorrhage in the treatment group,there was no statistical difference between the two groups（P>0.05）;1 case of pulmonary hemorrhage after removal of trachea intubation in the non-treatment group,3cases in the treatment group,there was no statistical difference between the two groups（P<0.05）.The hypoxemia,there were 3 cases（5.45%）in the non-treatment group（5.45%）,10 cases（27.78%）in the treatment group;The low cardiac output syndrome,5 cases（9.09%）in the non-treatment group,7 cases（19.44%）in the treatment group,;The mortality 1 case（1.82%）in the non-treatment group,and 5 cases（13.89%）in the treatment group.The incidence of hypoxemia,low cardiac output syndrome and mortality were lower than those in the on-treatment group after the radical surgery of tetralogy of Fallot.There is statistical significance between the two group（P<0.05）.The mechanical ventilation time（h）39.73±7.93 of the non-treatment group was less than the treatment group（h）59.25±13.68.The ICU hospitalization time（h）89.45±6.07 of the non-treatment group was less than the treatment group（h）114.13±22.36,and the comparison between the two groups was statistically significant（P<0.05）.Total hospitalization cost（yuan）non-treatment group69803.27±6783.34,lower than the treatment group86700.75±9637.32,the two groups were statistically significant（P<0.05）.Conclusion（1）Pulmonary hemorrhage after radical surgery of tetralogy of Fallot is related to the number,the maximum internal menstruation and average internal diameter of the MAPCAs.The maximum internal menstruation≥3mm is a risk factor for pulmonary hemorrhage and massive pulmonary hemorrhage after the radical surgery of TOF.（2）No treatment of the MAPCAs before the radical surgery of TOF,use the PEEP and other methods to prevent and treat pulmonary hemorrhage after the radical surgery of TOF will increase the risk of pulmonary hemorrhage after radical surgery of tetralogy of Fallot,but it does not increase the risk of massive pulmonary hemorrhage and the pulmonary hemorrhage after removal of trachea intubation,which can reduce the cost of hospitalization,reduce the incidence of hypoxemia,reduce the incidence of low cardiac output syndrome,reduce mortality.