Thompson L D, Petrossian E, McElhinney D B, Abrikosova N A, Moore P, Reddy V M, Hanley F L
Division of Cardiothoracic Surgery, University of California, San Francisco 94143-0118, USA.
J Am Coll Cardiol. 1999 Aug;34(2):539-44. doi: 10.1016/s0735-1097(99)00228-4.
This study was conducted to assess the need for, and use of, fenestration of an extracardiac conduit Fontan.
Fenestration of a Fontan connection has been proposed as a means of improving outcomes of single ventricle palliation. The benefit of fenestration is likely to be greatest in the early postoperative period when patients may experience increased pulmonary vascular resistance and decreased ventricular function due to the effects of cardiopulmonary bypass, aortic cross-clamping and positive pressure ventilation. However, there are potential drawbacks to fenestration. The utility of fenestration with extracardiac Fontan operation has not been determined.
Since 1992, 81 patients have undergone a modification of the Fontan procedure in which an extracardiac inferior cavopulmonary conduit is used in combination with a previously staged bidirectional Glenn anastomosis. We conducted a retrospective review of these patients.
Fenestration was performed selectively in 32 patients (39%), including only 2 of the last 38 (5%). In seven patients, a fenestration was placed or clipped in the early postoperative period without cardiopulmonary bypass. There were two operative deaths. Prolonged (>2 weeks) pleural drainage occurred in 13 patients, 8 with fenestration and 5 without. In addition to undergoing earlier Fontan in our experience, patients who had a fenestration placed had significantly higher preoperative pulmonary vascular resistance, significantly higher common atrial pressure after Fontan and significantly lower post-Fontan systemic arterial oxygen saturation. Fontan pressure did not differ between nonfenestrated and fenestrated patients. At follow-up ranging to five years, there were two late deaths and no patients developed protein losing enteropathy.
Fenestration is not necessary in most Fontan patients when an extracardiac conduit technique is performed as described in this article, and therefore, should not be performed routinely with the extracardiac conduit Fontan. The need for fenestration should be assessed after cardiopulmonary bypass when hemodynamics can be evaluated accurately. Fenestration can be placed and revised easily without bypass and with minimal intervention in patients with an extracardiac conduit Fontan.
本研究旨在评估心外管道Fontan手术开窗的必要性及应用情况。
Fontan连接开窗已被提议作为改善单心室姑息治疗效果的一种方法。开窗的益处可能在术后早期最为显著，此时患者可能因体外循环、主动脉阻断和正压通气的影响而出现肺血管阻力增加和心室功能下降。然而，开窗也存在潜在弊端。心外Fontan手术开窗的实用性尚未确定。
自1992年以来，81例患者接受了Fontan手术改良，采用心外下腔静脉-肺动脉管道并结合先前分期的双向Glenn吻合术。我们对这些患者进行了回顾性研究。
32例患者（39%）选择性地进行了开窗，其中最后38例中仅2例（5%）。7例患者在术后早期未进行体外循环的情况下放置或夹闭了开窗。有2例手术死亡。13例患者出现了长时间（>2周）的胸腔引流，其中8例有开窗，5例没有。根据我们的经验，除了更早接受Fontan手术外，进行开窗的患者术前肺血管阻力显著更高，Fontan术后共同心房压力显著更高，Fontan术后体循环动脉血氧饱和度显著更低。非开窗和开窗患者的Fontan压力没有差异。在长达五年的随访中，有2例晚期死亡，没有患者发生蛋白丢失性肠病。
当按照本文所述进行心外管道技术时，大多数Fontan患者不需要开窗，因此，不应在心外管道Fontan手术中常规进行开窗。在能够准确评估血流动力学的体外循环后，应评估开窗的必要性。对于心外管道Fontan患者，无需体外循环且干预最小的情况下，开窗可以轻松放置和修改。
