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\begin{document}

\title{Tricuspid valve detachment for ventricular septal defect closure: A
meta-analysis of existing evidence}



\author[1]{Dou Yuan}%
\author[1]{Li ping Chen}%
\author[1]{Xiao ling}%
\author[1]{Yongjun Qian}%
\affil[1]{Sichuan University West China Hospital}%


\vspace{-1em}



  
  \date{May 04, 2024}


\begingroup
\let\center\flushleft
\let\endcenter\endflushleft
\maketitle
\endgroup





\selectlanguage{english}
\begin{abstract}
\textbf{Background:} Ventricular septal defect (VSD) is one of the most
common congenital cardiac defects, However, in some cases VSD sites are
difficult to expose due to obstruction from chordal attachments and
leaflets of the tricuspid valve (TV){[}6{]}(\#ref-0006). To
systematically review the efficacy and safety of tricuspid valve
detachment,( TVD) versus conventional surgical repair ( non-TVD) in the
treatment of ventricular septal defect ( VSD) .This article is aimed to
compare the many outcomes from existing studies and provide evidence
regarding the necessity of performing TVD. \textbf{Methods:}We searched
the following databases: PubMed via NCBI, the Cochrane Central Register
of Controlled Trials (no date restriction),Medline via Ovid (from 1966
to May 2020); Embase via Ovid (no date restriction) and China National
Knowledge Infrastructure for studies comparing the efficacy of tricuspid
valve detachment (TVD) and other surgical techniques in VSD repair.
Cardiopulmonary bypass time, Cross-clamp time; postoperative
complications including residual defect ,Postoperative atrioventricular
block ,Implantation of pacemakers, tricuspid regurgitation ;Length of
stay, Length of ICU stay were analyzed. \textbf{Results:} Only 9
studies were included after selection (Table 1), including 7
retrospective cohort studies, 1 respective cohort study and 1
prospective observational stud,a patient pool of 1404 patients with 374
underwent TVD and 1030 underwent non-TVD procedures,met the inclusion
criteria.Meta analysis has drawn to the following conclusions.~Firstly,
TVD prolongs CPB time (MD=7.75, 95\% CI=2.60-12.89, p=0.003) and
cross-clamp time(MD=7.77, 95\% CI=4.76-10.78, p\textless{}0.001)
compared with non-TVD techniques in VSD repair surgeries.~Secondly, no
significant difference exists in LOS, length of ICU stay, postoperative
atrioventricular block, implantation of pacemakers, incidence of [?]mild
TR postoperatively and at discharge, as well as incidence of [?]small
residual VSD after surgery and during follow-up( all P > 0.
05).~Thirdly, application of TVD increases the risk of TR during
follow-up(OR=2.42, 95\% CI=1.55-3.76, p\textless{}0.001).
\textbf{Conclusion:} VSD closure using TVD technique results in longer
CPB and cross-clamp time, and increases risk of TR during follow-up. TVD
provides equally viable and safe alternative in treating VSD.%
\end{abstract}%



\sloppy


\textbf{Title page}

Tricuspid valve detachment for ventricular septal defect closure:

A meta-analysis of existing evidence

Dou Yuan ,M.D1 ;Li ping Chen ,M.D2 ;Xiao ling Zhang, M.D2; Yongjun Qian
,Ph.D3

1.Department of Cardiovascular Surgery, Cheng Du Shang Jin Nan Fu
Hospital, West China Hospital of Sichuan University, Chengdu, Sichuan,
China;

2. Department of~Cardiology, West China Hospital, Sichuan University,
Chengdu, Sichuan, China;

\textbf{3. Corresponding author:} Yong-Jun Qian

Tel: +86 28 85422897;Fax +86 28 85421833;

E-mail: qianyongjun@scu.edu.cn

Mailing Address: Department of Cardiovascular Surgery , West China
Hospital, Sichuan University, Chengdu, Sichuan, China,610041

\textbf{Data availability statement} : All data relevant to the study
are included in the article.

\textbf{Funding statement:} Not applicable.

\textbf{Conflict of interest disclosure:} None

\textbf{Institutional Review Board approval or waiver:} PROSPERO team
had reviewed and approval was obtained.

\textbf{Abstract}

\textbf{Background:} Ventricular septal defect (VSD) is one of the most
common congenital cardiac defects, However, in some cases VSD sites are
difficult to expose due to obstruction from chordal attachments and
leaflets of the tricuspid valve (TV)\textsuperscript{6}. To
systematically review the efficacy and safety of tricuspid valve
detachment,( TVD) versus conventional surgical repair ( non-TVD) in the
treatment of ventricular septal defect ( VSD) .This article is aimed to
compare the many outcomes from existing studies and provide evidence
regarding the necessity of performing TVD.

\textbf{Methods:} We searched the following databases: PubMed via NCBI,
the Cochrane Central Register of Controlled Trials (no date
restriction),Medline via Ovid (from 1966 to May 2020); Embase via Ovid
(no date restriction) and China National Knowledge Infrastructure for
studies comparing the efficacy of tricuspid valve detachment (TVD) and
other surgical techniques in VSD repair. Cardiopulmonary bypass time,
Cross-clamp time; postoperative complications including residual defect
,Postoperative atrioventricular block ,Implantation of pacemakers,
tricuspid regurgitation ;Length of stay, Length of ICU stay were
analyzed.

\textbf{Results:} Only 9 studies were included after selection (Table
1), including 7 retrospective cohort studies, 1 respective cohort study
and 1 prospective observational stud,a patient pool of 1404 patients
with 374 underwent TVD and 1030 underwent non-TVD procedures,met the
inclusion criteria.Meta analysis has drawn to the following
conclusions.~Firstly, TVD prolongs CPB time (MD=7.75, 95\%
CI=2.60-12.89, p=0.003) and cross-clamp time(MD=7.77, 95\%
CI=4.76-10.78, p\textless{}0.001) compared with non-TVD techniques in
VSD repair surgeries.~Secondly, no significant difference exists in LOS,
length of ICU stay, postoperative atrioventricular block, implantation
of pacemakers, incidence of [?]mild TR postoperatively and at discharge,
as well as incidence of [?]small residual VSD after surgery and during
follow-up( all P > 0. 05).~Thirdly, application of TVD increases the
risk of TR during follow-up(OR=2.42, 95\% CI=1.55-3.76,
p\textless{}0.001).

\textbf{Conclusion:} VSD closure using TVD technique results in longer
CPB and cross-clamp time, and increases risk of TR during follow-up. TVD
provides equally viable and safe alternative in treating VSD.

\begin{CJK}{UTF8}{gbsn}【\end{CJK}\selectlanguage{english}Key words\begin{CJK}{UTF8}{gbsn}】\end{CJK}\selectlanguage{english}Ventricular septal defect; Tricuspid valve detachment; Meta
analysis

\textbf{Introduction}

Ventricular septal defect (VSD) is one of the most common congenital
cardiac defects, occurring in 3570 infants per million live births on
average\textsuperscript{1}. Surgical closure of VSD was first attempted
by Lillehei and colleagues in 1955\textsuperscript{2}, and after six
decades of surgical practice and technical iteration, nowadays cardiac
surgeons can minimize the mortality rate after VSD repair thanks to
comprehensive application of cardiopulmonary bypass (CPB) practices,
myocardial preservation techniques, improved anesthesia and careful
postoperative care\textsuperscript{3-5}.

The transatrial approach for VSD repair is most widely accepted surgical
technique and can enable adequate exposure of the margins of the defect,
thus facilitate complete repairs. However, in some cases VSD sites are
difficult to expose due to obstruction from chordal attachments and
leaflets of the tricuspid valve (TV)\textsuperscript{6}. Incomplete
repair of VSD increases the incidence of morbidities like complete heart
block, tricuspid valve regurgitation (TR) and residual VSD, leading to
compromised surgical efficacy or even death\textsuperscript{5-7}.

To achieve optimal visualization of hard-to-expose VSD, detachment of
the TV, radical incision of the TV from leaflet edge to the annulus or
detachment of chordal have been suggested, and existing data shows
promising results\textsuperscript{8-10}. However, controversies
surrounding whether or not tricuspid valve detachment (TVD) procedure
should be performed on patients still exists, some specialists argue
that TVD may prolong CPB time and cross-clamp time\textsuperscript{5,7};
whereas some others believe when following certain inclusion criteria
for TVD, the procedure can significantly improve surgical
efficacy\textsuperscript{11}. This article is aimed to compare the many
outcomes from existing studies and provide evidence regarding the
necessity of performing TVD.

\textbf{Methods}

\textbf{2.1 Search strategy}

A systematic review of published articles was conducted according to the
protocol specified by the Cochrane collaboration\textsuperscript{12} and
reported in line with the Preferred Reporting Items for Systematic
Reviews and Meta-Analyses (PRISMA) statement for conducting
meta-analyses on intervention studies\textsuperscript{13}. We searched
the following databases: PubMed via NCBI, the Cochrane Central Register
of Controlled Trials (no date restriction), Medline via Ovid (from 1966
to May 2020); Embase via Ovid (no date restriction) and China National
Knowledge Infrastructure for studies comparing the efficacy of tricuspid
valve detachment (TVD) and other surgical techniques in VSD repair. No
restriction was put onto publication type or reporting language.
Searching terms included: ``ventricular septal defect,'' ``tricuspid
valve,'' and ``detachment.'' Furthermore, conference proceedings of
important international conferences like Society of Thoracic Surgeons
(STS), American Heart Association (AHA) and European Society of
Cardiology (ESC) were also consulted.

\textbf{2.2 Study Characteristics}

Studies were included in this meta-analysis only after all the following
inclusion criteria were met:

\begin{enumerate}
\tightlist
\item
  Randomized controlled trials or cohort studies comparing TVD and other
  techniques with no fewer than 10 patients in each group;
\item
  Demographic data and comorbidities of the patients (postoperative, at
  discharge or during follow-up) were provided;
\item
  Diagnosis of VSD had been made by transesophageal echocardiogram (TEE)
  or transthoracic echocardiogram (TTE) prior to surgery;
\item
  At least 1 of the basic outcome criteria (CPB time, cross-clamp time,
  postoperative morbidities) was provided;
\end{enumerate}

It is worth noting that an extensive effort was made to minimize the
impact of convert duplicate or metachronous republication from the same
surgical groups on the patient sample size. For these cases, only the
latest studies were included. Also, if a surgical group was found to
have participated in multiple studies, only the study with the largest
patient population will be included.

\textbf{2.3 Data extraction}

Inclusion and exclusion criteria were defined to determine the selection
of clinical studies. References of all included articles were manually
examined and added to our electronic citation manager to ensure that all
pertinent published works had been identified. With no prior knowledge
of the authors or results of the selected publications, 2 reviewers (Cao
Z and Ling Y) rated the clinical and methodological quality of each
study using a standardized scoring system independently after acquiring
full texts of the studies. Studies that did not rate above a quality
score threshold were excluded from data extraction.

\textbf{2.4 Outcome measures}

Primary outcomes of the meta-analysis included procedural outcomes like
CPB time and cross-clamp time. The secondary outcomes included
procedural outcomes like implantation of pacemakers and postoperative
atrioventricular block, as well as clinical outcomes like length of stay
(LOS), length of ICU stay, incidence of [?]mild TR after surgery, at
discharge and during follow-up, incidence of [?]small residual VSD after
surgery and during follow-up. Risk of bias assessment was performed
according to the Newcastle--Ottawa Quality Assessment
Scale\textsuperscript{14} criteria. [?]mild TR was defined as TR with a
grade of [?]2 using TTE or TEE. [?]small residual VSD was defined as
residual VSD with a diameter of [?]2 mm after surgical repair.

\textbf{2.5 Meta Analysis}

Statistical analysis was performed using RevMan software (Review Manager
version 5.3, Nordic Cochrane Centre, Copenhagen, Denmark). A p-value of
\textless{}0.05 was considered significant. Mean difference with a 95\%
confidence interval was utilized to describe continuous outcomes, and
odds ratio with a 95\% confidence interval was used to describe
dichotomous outcomes. A random effects model was used in case of
significant heterogeneity, and a fixed effect model was applied when
heterogeneity was low. Heterogeneity was assessed using the Cochrane Q
square test (P \textless{} 0.05 was considered an indicator of
significant heterogeneity) and the I\textsuperscript{2} estimates (
\textless{} 50\% low heterogeneity, \textgreater{} 50\% high
heterogeneity).

\textbf{3.Results}

\textbf{3.1 Eligible studies and characteristics of studies}

A total of 120 articles were identified, and 80 remained after title
abstract screen and duplicate deletion. Altogether 71 articles were
excluded for the following reasons: 33 articles were case reports,
reviews or case series; 20 studies included no VSD patients; 12 studies
performed no TVD procedure; 3 studies provided inadequate raw data for
analysis; and 2 studies included insufficient patient population (Figure
1).

Only 9 studies were included after selection (Table 1), including 7
retrospective cohort studies, 1 respective cohort study and 1
prospective observational study. Quality assessment of included studies
was summarized in Table 2. In the study led by
Sasson\textsuperscript{11}, patients were divided into three groups,
group 1 included patients with no indication for TVD, group 2 for
patients with indications for TVD and underwent TVD and group 3 for
patients with indications for TVD but underwent non-TVD procedures. Our
analysis took only group 2 and group 3 into consideration.

\textbf{3.2 Patient characteristics}

All selected studies formed a patient pool of 1404 patients with 374
underwent TVD and 1030 underwent non-TVD procedures.

Based on existing data, mean age was 12.96 months and 8.15 months
(p=0.1752), mean weight was 6.62 kg and 6.74 kg (p=0.8362) respectively
for TVD and non-TVD group. Weighted mean follow-up time was 39.89\selectlanguage{ngerman}±24.24
months in TVD group and 43.36±27.15 months in non-TVD group.

\textbf{3.3 Procedural outcomes}

\textbf{3.3.1Cardiopulmonary bypass time}

Mean CPB time was 82.55 minutes with 95\% CI of 79.89-85.21 minutes in
the TVD group and 73.78 minutes with 95\% CI of 72.26-75.31 minutes in
the non-TVD group (p\textless{}0.001). 374 patients receiving TVD and
1030 patients receiving non-TVD procedures were assessed for this
outcome and recruited from all 9 included studies.

In the meta-analysis, significant difference in CPB time was identified
(MD=7.75, 95\% CI=2.60-12.89, p=0.003) (\textbf{Fig.2a} ).

\textbf{3.3.2Cross-clamp time}

Mean cross-clamp time was 52.02 minutes with 95\% CI of 50.02-54.02
minutes in the TVD group and 43.70 minutes with 95\% CI of 42.66-44.74
minutes in the non-TVD group (p\textless{}0.001). 333 patients receiving
TVD and 977 patients receiving non-TVD procedures were assessed for this
outcome and recruited from 8 included studies.

In the meta-analysis, significant difference in cross-clamp time was
identified (MD=7.77, 95\% CI=4.76-10.78, p\textless{}0.001)
(\textbf{Fig.2b} ).

\textbf{3.3.3Postoperative atrioventricular block}

The meta-analysis for postoperative atrioventricular block included 193
patients undergoing TVD and 479 patients undergoing non-TVD procedures
from 4 studies, no significant difference in postoperative
atrioventricular block was identified(OR=0.73, 95\% CI=0.18-3.01,
p=0.66) (\textbf{Fig.2c} ).

\textbf{3.3.4}

\textbf{Implantation of pacemakers}

The meta-analysis for implantation of pacemakers included 125 patients
undergoing TVD and 456 patients undergoing non-TVD procedures from 3
studies, no significant difference in implantation of pacemakers was
identified(OR=0.95, 95\% CI=0.19-4.71, p=0.95) (\textbf{Fig.2d} ).

\textbf{3.4 Clinical outcomes}

\textbf{3.4.1} \textbf{Length of stay}

Mean LOS was 5.74 days with 95\% CI of 5.06-6.43 days in the TVD group
and 5.6 days with 95\% CI of 4.08-7.12 days in the non-TVD group
(p=0.9182). 132 patients receiving TVD and 411 patients receiving
non-TVD procedures were assessed for this outcome and recruited from 2
included studies.

In the meta-analysis, no significant difference in LOS was identified
(MD=0.01, 95\% CI=-0.23-0.24, p=0.96) (\textbf{Fig.3a} ).

\textbf{3.4.2} \textbf{Length of ICU stay}

Mean length of ICU stay was 5.74 days with 95\% CI of 5.06-6.43 days in
the TVD group and 5.6 days with 95\% CI of 4.08-7.12 days in the non-TVD
group (p=0.9182). 132 patients receiving TVD and 411 patients receiving
non-TVD procedures were assessed for this outcome and recruited from 2
included studies.

In the meta-analysis, no significant difference in length of ICU stay
was identified (MD=-0.14, 95\% CI=-1.31-1.03, p=0.82) (\textbf{Fig.3b}
).

\selectlanguage{english}\textbf{3.4.3 Postoperative [?]mild TR}

The meta-analysis for postoperative \selectlanguage{english}[?]mild TR included 205 patients
undergoing TVD and 515 patients undergoing non-TVD procedures from 4
studies, no significant difference in postoperative \selectlanguage{english}[?]mild TR was
identified(OR=1.05, 95\% CI=0.53-2.09, p=0.88) (\textbf{Fig.3c} ).

\selectlanguage{english}\textbf{3.4.5 [?]mild TR at discharge}

The meta-analysis for \selectlanguage{english}[?]mild TR at discharge included 67 patients
undergoing TVD and 142 patients undergoing non-TVD procedures from 2
studies, no significant difference in \selectlanguage{english}[?]mild TR at discharge was
identified(OR=0.70, 95\% CI=0.30-1.60, p=0.40) (\textbf{Fig.3d} ).

\selectlanguage{english}\textbf{3.4.6 [?]mild TR during follow-up}

The meta-analysis for \selectlanguage{english}[?]mild TR during follow-up included 250 patients
undergoing TVD and 813 patients undergoing non-TVD procedures from 7
studies, significant difference in \selectlanguage{english}[?]mild TR during follow-up was
identified(OR=2.42, 95\% CI=1.55-3.76, p\textless{}0.001)
(\textbf{Fig.3e} ).

\selectlanguage{english}\textbf{3.4.7 Postoperative [?]small residual VSD}

The meta-analysis for postoperative \selectlanguage{english}[?]small residual VSD included 113
patients undergoing TVD and 284 patients undergoing non-TVD procedures
from 3 studies, no significant difference in postoperative \selectlanguage{english}[?]small
residual VSD was identified(OR=0.74, 95\% CI=0.42-1.29, p=0.29)
(\textbf{Fig.3f} ).

\selectlanguage{english}\textbf{3.4.8 [?]small residual VSD during follow-up}

The meta-analysis for \selectlanguage{english}[?]small residual VSD during follow-up included 98
patients undergoing TVD and 400 patients undergoing non-TVD procedures
from 3 studies, no significant difference in \selectlanguage{english}[?]small residual VSD during
follow-up was identified(OR=0.86, 95\% CI=0.26-0.87, p=0.81)
(\textbf{Fig.3g} ).

\textbf{4.Discussion}

Detachment of the septal leaflet of tricuspid valve was first attempted
by Hudspeth and colleagues in 1962 to achieve optimal visualization of
VSD in surgical repair\textsuperscript{15}. And in the last few decades
several studies applied TVD techniques to repair hard-to-expose VSD
sites, but the majority of which were single institution cohort studies
with limited sample sizes and high risk of bias.

This meta-analysis was designed to evaluate and compare important
procedural and clinical outcomes after VSD repair using TVD and non-TVD
techniques. To date this is the most comprehensive comparative analysis
focusing on the efficacy and safety of TVD in surgical repair of VSD.
This analysis has drawn to the following conclusions. Firstly, TVD
prolongs CPB time and cross-clamp time compared with non-TVD techniques
in VSD repair surgeries. Secondly, no significant difference exists in
LOS, length of ICU stay, postoperative atrioventricular block,
implantation of pacemakers, incidence of \selectlanguage{english}[?]mild TR postoperatively and at
discharge, as well as incidence of \selectlanguage{english}[?]small residual VSD after surgery and
during follow-up. Thirdly, application of TVD increases the risk of TR
during follow-up.

There have been worries that prolonged CPB and cross-clamp time during
surgeries using TVD techniques may harbor additional ischemic damages,
and that a more complicated technique may do harm to the conduction
system and change the geometry of the heart. However, our meta-analysis
has shown that although TVD procedure requires longer CPB and
cross-clamp time to be completed, it did not result in any significant
differences in clinically relevant outcomes except incidence of TR
during follow-up compared with non-TVD procedures. The following factors
may contribute to this finding. As has been exemplified in the study led
by Sasson\textsuperscript{11}, most included studies allocate patients
into TVD group under strict criteria to maximize patients' benefit from
TVD: (1) multiple tricuspid valve chordal arrangement obscuring the
margins of the defect; (2) tricuspid valve aneurysm that precludes easy
access to the defect; and (3) high position of the defect with outlet
extension requiring excessive traction on the tricuspid valve leaflet
for exposure. During surgery, an incision parallel to the
atrioventricular groove on the right atrium was suggested to reduce the
risk of damaging the conduction system. In addition, marking sutures was
used at the beginning and end of the detachment to enhance positioning
accuracy. After closure, cold saline was injected into the ventricle to
assess TV leaflet competence and coaptation, and reoperation was applied
immediately should any issues occur.

As for why the incidence of TR is relatively high in the TVD group
during follow-up, to date no studies have raised concerns on this topic.
We speculate that the reason may be Prolene sutures used to reattach
detached leaflets or chordae gradually become incompatible to the
healing and renewing tissue. In addition, minor errors during
reattachment after TVD maybe amplified by the change of heart size and
adapting hemodynamics. This result serves as a reminder that achieving
separation of the body and lung circulations should not be the only goal
of VSD closure, mitigating trauma to the myocardium and preservation of
heart geometry should also be surgeons' main
consideration\textsuperscript{4}.

\textbf{5. Conclusion}

In summary, VSD closure using TVD technique results in longer CPB and
cross-clamp time, and increases risk of TR during follow-up. Studies
with longer follow-up periods, more detailed clinical data and lesser
risk of bias are needed to further testify the effectiveness of TVD
technique.

\textbf{Conflicts of interest} \selectlanguage{english}:The authors declare that there are no
conflict of interests

\textbf{Author contribution statement} : Yongjun Qian:
Conceptualization, Methodology, Supervision; Dou Yuan: Writing- Original
draft preparation; Liping Chen: Writing-Review \& Editing. Xiaoling
Zhang: Editing. All authors read and approved the final version of the
manuscript.

\textbf{Abbreviation and Acronyms}

CPB = cardiopulmonary bypass

LOS = length of stay

MD = mean difference

RO = risk ratio

TEE = transesophageal echocardiogram

TVD = tricuspid valve detachment

TR = tricuspid valve regurgitation

TTE = transthoracic echocardiogram

VSD = ventricular septal defect\selectlanguage{english}
\begin{longtable}[]{@{}llllll@{}}
\toprule
ID & Author/Year & Country & No. of patients & No. of patients & Study
design\tabularnewline
\midrule
\endhead
& & & TVD & Non-TVD &\tabularnewline
1 & Bilen/2020\textsuperscript{16} & Turkey & 50 & 120 & Retrospective
cohort\tabularnewline
2 & Fraser/2018\textsuperscript{10} & USA & 83 & 164 & Retrospective
cohort\tabularnewline
3 & Pourmoghadam/2018\textsuperscript{5} & USA & 26 & 89 & Retrospective
cohort\tabularnewline
4 & Bang/2016\textsuperscript{7} & Korea & 49 & 247 & Retrospective
cohort\tabularnewline
5 & Bol-Raap/2003\textsuperscript{17} & Netherlands & 46 & 142 &
Retrospective cohort\tabularnewline
6 & Aeba/2003\textsuperscript{18} & Japan & 23 & 64 & Retrospective
cohort\tabularnewline
7 & Gaynor/2000\textsuperscript{19} & USA & 36 & 136 & Retrospective
cohort\tabularnewline
8 & Weymann/2013\textsuperscript{6} & Germany & 20 & 15 & Respective
cohort\tabularnewline
9 & Sasson/2006\textsuperscript{11} & Isarel & 41 & 53 & Prospective
observational\tabularnewline
\bottomrule
\end{longtable}

\textbf{Table 1} -- Characteristics of included studies.\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image1/image1}

\end{center}
\end{figure}

\textbf{Table 2} -- Risk of bias summary and table.\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image2/image2}

\end{center}
\end{figure}

\textbf{Figure 1} -- Flow diagram demonstrating the selection of studies
for the meta-analysis.\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image3/image3}

\end{center}
\end{figure}

\textbf{Figure 2} -- Forest plot of procedural outcomes.

(a) Cardiopulmonary bypass time (min);

(b) Cross-clamp time (min);

(c) Postoperative atrioventricular block;

(d) Implantation of pacemakers.\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image4/image4}

\end{center}
\end{figure}

\textbf{Figure 3} -- Forest plots of clinical outcomes.

(a) Length of stay (day); (b) Length of ICU stay (day);

(c) incidence of [?]mild postoperative tricuspid regurgitation;

(d) [?]mild tricuspid regurgitation at discharge;

(e) [?]mild tricuspid regurgitation during follow-up;

(f) [?]small postoperative residual ventricular septal defect;

(g) [?]small residual ventricular septal defect during follow-up.

\textbf{References:}

1. Hoffman JI, Kaplan S. The incidence of congenital heart
disease.\emph{J Am Coll Cardiol.} 2002;39(12):1890-1900.

2. Lillehei CW, Cohen M, Warden HE, Ziegler NR, Varco RL. The results of
direct vision closure of ventricular septal defects in eight patients by
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