Academician Wang began to talk about the Fontan operation.

"It's a bit complicated to say in three steps, I still use the flashback method to say, first talk about the result, that is, the goal to be achieved in three steps, why can't it be done in one step, because the heart is transformed and there is a process of adaptation, and the heart can't stand it in one step, and there will be serious complications, so it can only be done slowly step by step, so that the heart can slowly adapt."

"You look at this case, the left ventricle is very small and underdeveloped, what should we do, we don't want this left ventricle, discard it, doesn't the heart have a right ventricle? It can also pump blood, so we connect the aorta to the right ventricle and let the right ventricle replace the left ventricle; It turns out that the right ventricle is connected to the pulmonary artery and is the driving force of the pulmonary circulation. The soul of Fontan surgery is here, didn't I say it before, the core of this surgery is that the pulmonary artery and the superior and inferior vena cava are directly shorted, without passing through the heart, kicking the heart as a power source, and letting their pressure difference provide the driving force; Finally, knock down the partition walls between the left and right atriums and make them a room, so that the three points are the result we want, but this result is achieved in three steps. ”

"What happens to the heart after surgery?"

"Let's see!"

Academician Wang drew a picture on the electronic blackboard: "My drawing is not as high as Professor Yang's, so let's make do with it." ”

In fact, as a medical drawing, Academician Wang is already at a very high level.

"The systemic circulation becomes like this – oxygen-rich arterial blood travels from the pulmonary veins back to the left atrium, then through the surgically created opening between the two atrium, into the right atrium, then into the right ventricle, where it is pumped from the aorta throughout the body as the heart beats, and finally collected by the superior and inferior vena cava.

"What about the pulmonary circulation, like this - oxygen-poor blood enters the pulmonary artery directly from the superior and inferior vena cava, and after gas exchange in the lungs, it becomes oxygen-rich blood, and returns to the left atrium through the pulmonary vein.

You see, a man-made transformation of the circulation has been successfully established, and the goal has been achieved: oxygen-rich blood is separated from oxygen-poor blood, and the heart is only responsible for systemic circulation, and this transformation is to use the recombination of factory substandard accessories to achieve normal function.

"Isn't it interesting to compare the normal systemic and pulmonary circulation, what an imaginative approach."

Next, Academician Wang explained in detail the specific methods of staging surgery, the first stage is generally completed within one month, the second stage is half a year old, and the third stage is one to one and a half years old.

"The first step is to enlarge the aorta, because the left ventricle connects to the aorta, since the left ventricle is underdeveloped, often the aorta is also underdeveloped, very thin, we want to enlarge the aorta, and then cut the pulmonary artery connecting to the right ventricle, and then connect the aorta with the right ventricle, so that the right ventricle replaces the left ventricle to complete the systemic circulation. So what about the abandoned pulmonary circulation? We bridge the pulmonary artery with the aorta, and this bridging is temporary. In fact, the circulation is still chaotic, oxygen-rich and oxygen-poor blood are mixed, that is, the purpose has not been achieved, but this is only the first step, although the final goal has not been achieved, but it can ensure that the child will live to the second step of surgery. Of course, in this step, we also need to open up the separation between the left and right atrium. ”

"After the heart adapts, we carry out the second step when he is half a year old, it turns out that we have built a bridge between the aorta and the pulmonary artery, this bridge is only temporary, and now it is to be removed, and the superior vena cava is connected to the pulmonary artery, so that the pulmonary artery receives oxygen-poor venous blood, which is one step closer to the goal, but the blood from the inferior vena cava will still enter the right atrium, the left atrium and the right ventricle that acts as the left ventricle, so in the second step, the venous blood and the arterial blood will mix."

"At the age of one to one and a half, we take the final step of connecting the inferior vena cava to the pulmonary artery, and let's see, have we achieved what we started to do?"

Academician Wang used plain language to explain the three steps of Fontan surgery clearly, and combined with the drawing, the young students have fully understood.

"Throughout the operation and postoperative monitoring, we focus on monitoring the pulmonary artery pressure, because the foundation of the whole operation is based on the pressure difference between the aorta and the pulmonary artery, so once the pulmonary artery is hypertensive, the whole surgical effect will collapse, and the patient will be in danger, so once we find a problem, we need surgery to adjust the pulmonary artery pressure."

"To sum up, our goal is to change the aorta that originally connected the left ventricle to the right ventricle because the left ventricle is invalid, and to connect the pulmonary artery that originally connected to the right ventricle to the superior and inferior vena cava; Open the interval between the left and right atrium. ”

"It's just that in order to let the heart adapt, we take our time and complete the goal in three steps - first change the aorta to the right ventricle, at this time the pulmonary artery is not yet connected to the superior and inferior vena cava, so temporarily build a channel with the aorta; The aorta is then connected to the superior vena cava; Finally, connect the aorta to the inferior vena cava, and you're done! ”

"Is there anything I don't understand about the Fontan procedure, or if there's anything I want to ask?" Academician Wang asked.

A student raised his hand: "Mr. Wang, in addition to heart transplantation, will there be a new method to cure this disease in the future?" ”

Academician Wang said: "I'm not sure, at the current level of medicine, except for heart transplantation, there is no way to cure it, but this only refers to the existing, just within the scope of my cognition, isn't there no way to have tricuspid valve atresia before?" Fontan surgery will not save lives, and the next radical surgery, I think it should be among you. ”

After Academician Wang finished speaking, everyone was silent, and they didn't think of asking any questions for a while.

In order not to let the scene go cold, Yang Ping said at this time: "Let's think about it, what is the best way, think boldly, you can do whatever it is ridiculous and unconsuming, for example, isn't this case left ventricular dysplasia?" Can we bury a dilator in the left ventricle and slowly expand it to a normal size? We first do a Fontan procedure for temporary use, and at the same time implant a dilator in the left ventricle, when the left ventricle is dilated, we remove the Fontan procedure and bring the blood vessels back to their correct position. ”

When Academician Wang heard this, he was directly shocked by Yang Ping's idea, which can indeed be called "bold and absurd", and no one has thought about it yet.

For a long time, everyone thought that the left ventricle was underdeveloped and very small, so it could not be used, and in addition to heart transplantation, there was only Fontan surgery, and Fontan surgery was only palliative surgery, which only used the disabled heart to work normally.

No one has ever tried to normalize the stunted left ventricle.

Yes! Can you make a dilator, bury it in the left ventricle, and slowly expand it, everyone was immediately activated by the topic thrown by Yang Ping.

The idea of a real genius, the brain of a genius is different, Li Zehui and Professor Chen were both stunned by this kind of whimsical idea.

One of the students began to speak:

"The left ventricle is already small, and if it is artificially enlarged, will the myocardial wall be thinner and thinner, and the pulse will be weak or burst?"

Everyone saw that this classmate's idea did not arouse ridicule, so many people became bold.

"Yes, when you do the expansion flap, the bigger the spreader, the thinner the skin, it's like a dough, you have to make the area bigger, the thickness will be thinner."

Students are active in thinking, very imaginative, as soon as everyone's self-confidence comes up, they are bold, they dare to speak, no matter whether they are reliable or not, they dare to say their thoughts anyway.

"The child is still growing and developing, the heart is also growing and developing, and it is not a constant thing, according to the Ilizarov principle, the stretched tissue will grow faster." Li Guodong said excitedly.

"Wouldn't such a large dilator in the left ventricle cause a blood clot?" A girl asked.

"Just now it doesn't mean that this case has given up the left ventricle, because it is too small and useless, just so we will completely close the left ventricle and the left atrium, and then there will be no blood in the left ventricle, so that there is no thrombosis problem when the dilator is placed, and when the left ventricle is well developed, we will take out the dilator, and then open the interval between the closed left atrioventricles." The other boy immediately picked up.

I didn't expect these students to have such a rich imagination, Yang Ping was very happy in his heart, he just liked this kind of atmosphere, everyone dared to speak, how good it was.

Academician Wang was also surprised that these children's ideas were quite bold and novel.

"If you bury a dilator in the hypoplastic left ventricle, how do you dilate it? When we usually do skin expansion, there is a water bladder buried in the skin expander, and then a tube connected to the water bladder is led out and exposed, and water is regularly injected into the water bladder through the tube to achieve gradual expansion, how to achieve the heart? ”

Li Guodong asked.

"yes, how do you expand?"

The young doctors scratched their heads, yes, how to dilate, it can't lead a tube out of the heart like dilating the skin.

It's a ridiculous idea, but the progress of medicine is about bringing some seemingly ridiculous ideas to life.

"Can you draw a small tube out of the blood vessel, like a dialysis fistula, inject water into it when needed, and then close it after the injection?"

"The blood vessels are not good, there are tubes in the blood vessels, and soon a thrombus will form, and the entire blood vessel will be blocked, and the left ventricle is no longer involved in the circulation, and it cannot be guided into the blood vessels."

Song Zimo also participated in the discussion at this time: "The left ventricle does not participate in the circulation, things are easy to do, refer to the ventricular drainage of neurosurgery, directly fix the tube of the left ventricle, and design a way to lead it out." ”

"It can't come out of the chest cavity, the chest cavity is negative pressure, even if it is buried under the skin, in case of air leakage in the tunnel, after surgery or when the skin is cut in the future, the air will enter the chest cavity along the tube, through the gap between the tube and the tunnel, and a pneumothorax will be formed." Professor Chen was also excited.

"Referring to the ventricular shunt, after the drainage tube is drawn out of the left ventricle, it is introduced into the abdominal cavity from the thoracic cavity through the diaphragmatic hiatus, and then the abdominal cavity is led out to the subcutaneous area, buried in the skin fold next to the navel.

Discussing this, Academician Wang found that this plan for burying the dilator actually has a prototype, how to bury it, how to go through the pipeline, how to expand, and there is a specific implementation plan.

This comprehensive surgery is amazing, and it will be a gathering place for geniuses in the future, and the reference ventricular shunt proposed by Dr. Song just now opened up the mind.

"The biggest problem after left ventricular dilation -—— -—— how the separation between the left ventricle and the left atrium – aka the mitral valve – recovers – and I think that's the biggest – problem!"

Xu Zhiliang's speech.

This guy actually used this way to put the stuttering between reasonable sentences, although he said it slowly, but it was easy for everyone to understand.

Yes, mitral valve reopening is a difficult point?

Song Zimo thought for a while and said: "It's not difficult, the valve exists, there is a basis for sutures, and mitral valve replacement surgery can be performed." ”

"There is another question, we know - when we use the Ilyzalov theory to -—— bone lengthening -——, the bottleneck that limits bone lengthening is limited to the extension of nerves -—— nerves-—— beyond a certain limit will be apraxia - whether there will be conduction block -—— during the dilation process-—— that is, the conduction tract of the heart will be apraxia due to distraction."

The discussion became more and more in-depth, and Academician Wang sat down and listened carefully.

"This possibility exists or does not exist, we can accumulate some data through animal experiments, and then gradually collect data in the clinic, and gradually optimize, it is certain that if this possibility exists, then there must be a critical value between apraxia and normal."

"I think this idea is really good, you can do a topic to study, it has a great future, no matter whether it succeeds or fails in the future, at least explore a new way." Academician Wang became excited, and he recognized this proposal more and more.

Although it is absurd, although it is very unrealistic, many innovations start with the bold and absurd, and many innovations come through the absurdity and impracticality.

PS: Two chapters, more than 8,000 words, it's a small explosion! Thank you, and for your encouragement, smash the votes! Thank you!!!

(End of chapter)