Efficacy Analysis And Perioperative Management Strategies For Patients With Congenital Heart Disease Complicated With Pulmonary Hypertension

Objective:To analyze the risk factors of adverse events and the improvement of right atrial size before and after surgery in patients with congenital heart disease with pulmonary arterial hypertension(CHD-PAH)so as to improve the clinical results for these patients.Methods:From June 2014 to June 2016,79 patients with CHD-PAH underwent the surgical repair.There were 25 males and 54 females,aged from 18 to 61 years old.Newly diagnosed,to diagnosis PAH and the reactivity pulmonary vascular by right heart catheterization and oxygen experiment,13 cases with pulmonary vascular resistance(PVR)<lOWood units,Qp/Qs≥1.5,Sa02≥95%underwent the surgical repair directly.The remaining 66 patients received the targeted therapy three months,then made final decision on the base of the right review the right heart catheterization.Results:The early postoperative adverse events included pulmonary crisis in 11 patients,tracheotomy with the breath machine removing difficulty in 4 patients,low cardiac output syndrome occured in 2 patients;and there were 53 patients with postoperative right atrial returned to normal size.The preoperative PVR≥10 Wood units,Qp/Qs,SaO2,systolic pulmonary arterial pressure/systolic blood pressure(SPAP/SBP)>0.75,SPAP,DPAP(P<0.01)were the influence factors of the early postoperative adverse events.Univariate analysis revealed the higher the Sa02(OR＝0.584,P=0.015),the lower incidence of adverse events.Preoperative PVR≥10 Wood units,right atrial pressure(RAP)>8 mmHg,shunting direction(P<0.05)were the impact factors of right atrial enlargement.Univariate analysis revealed RAP>8 mmHg(OR = 3.398,P=0.029)was the independent risk factors of right atrial improvement.Conclusion:The risk factor for postoperative adverse events in CHD-PAH patients was the reduction of SaO2,and the risk factor for right atrial improvement was RAP>8 mmHg.OBJECTIVE:To investigate the bias and the limits of agreement(LOA)of central venous oxygen saturation(ScvO2)and mixed venous oxygen saturation(SvO2)in patients with pulmonary arterial hypertension(PAH)after repairment of congenital heart disease(CHD).METHODS:Prospective controlled study.Patients:43 patients with CHD-PAH,215 pairs of ScvO2 and SvO2,which were measured after the cardiopulmonary bypass(CPB)and 6,12,24,and 48 hours after admission to the intensive care unit(ICU).In addition,the hemodynamic parameters,hemoglobin,arterial lactate,and the postoperative duration of mechanical ventilation were recorded.Data were analysis by Bland-Altman,and linear regression analysis.Results:Regression analysis for the pooled measurements of ScvO2 and SvO2 showed the correlation R2 =0.369,after CPB R2 =0.515,6h after admission to ICU R2 =0.375,at 12h R2 =0.605,at 24h R2 =0.712,at 48h R2 =0.252.Bland-Altman analysis for the pooled measurements of ScvO2 and SvO2 showed that the mean bias is-1.3%,LOA is-17.0%to+14.4%.Almost no factor of recorded parameters influenced the △ScvO2-SvO2:oxygen extraction rate(O2ER)(R2=0.03,P=0.01),pulmonary artery systolic pressure(SPAP)(R2 = 0.03,P = 0.03),heart rate(HR)(R2 = 0.032,P =0.01),But in patients with ScvO2<70%the results are different:O2ER(R2=0.203,P<0.001),SPAP(R2 = 0.11,P=0.005),HR(R2 = 0.15,P<0.05),multiple linear regression showed that high correlations of O2ER(P<0.01),SPAP(P<0.05),HR(P<0.05)were observed with regard to △ScvO2-SvO2(R2 = 0.36,P<0.01).In patients with a low ScvO2 there was a trend to underestimate SvO2 by using ScvO2,and ScvO2 will overestimate SvO2 with a high ScvO2.Bland-Altman analysis of ScvO2 and SvO2 with the mechanical ventilation:mean bias was-1.3%,LOA was-16.1%to +13.5%.The only factor that influenced the△ScvO2-SvO2 is O2ER(R2 = 0.122,P<0.001).Bland-Altman analysis of ScvO2 and SvO2 without the mechanical ventilation:mean bias was-1.3%,LOA was-19.5%to+16.8%,and the factors influencing △ ScvO2-SvO2 were as follows:O2ER(R2 = 0.32,P<0.001),arterial S02(R2 = 0.32,P = 0.001).Conclusion:In patients with PAH after repairment of CHD,regardless of whether or not mechanical ventilation is applied,ScvO2 cannot be used as an estimate of SvO2 with acceptable accuracy.Especially with a high ScvO2,ScvO2 will overestimate SvO2.Therefore,ScvO2 and SvO2 should be monitored respectively in selective patients to exclude the hypoperfusion state.