Airan B, Sharma R, Choudhary S K, Mohanty S R, Bhan A, Chowdhari U K, Juneja R, Kothari S S, Saxena A, Venugopal P
Cardiothoracic Sciences Centre, All India Institute of Medical Sciences, Ansari Nagar, New Delhi.
Ann Thorac Surg. 2000 Jun;69(6):1900-6. doi: 10.1016/s0003-4975(00)01247-9.
A decade after the introduction of baffle fenestration, the outcome of Fontan-type repair for hearts with a functional single ventricle finally looks promising. Our study was designed to assess the impact of fenestration on the outcome of univentricular repairs.
From January 1988 to December 1997, 348 patients (104 with tricuspid atresia and 244 with other morphological diagnoses) underwent univentricular repair at our institute. Since 1994, routine fenestration of the atrial baffle was performed in all patients (n = 126).
The overall Fontan failure rate was 14% (50 of 348) and included 45 early deaths and five Fontan take downs. Absence of fenestration was the only and highly significant predictor of Fontan failure (risk ratio [RR] 3.3, 95% confidence interval [CI] 1.49 to 7.31, p = 0.002). Significant pleural effusion was seen in 27% of patients. Absence of fenestration of the atrial baffle (RR 3.97, 95% CI 2.17 to 7.26, p < 0.001) and aortic cross-clamp time more than 60 minutes (RR 2.15, 95% CI 1.3 to 3.5, p = 0.002) were found to be significant risk factors. The follow-up ranged from 6 to 120 months (mean 46.0 +/- 18.0 months). There were 12 late deaths and 5 patients were lost to follow-up. Actuarial survival (Kaplan Meier) at 90 months was 81% +/- 4%. Two hundred and fifty-eight patients (90%) were in New York Heart Association class I at their last follow-up visit. Oxygen saturation in the fenestrated group ranged from 85% to 94% (mean 89%). Thirty patients (26%) had spontaneous closure of the fenestration over a mean period of 34 months, and there has been no incidence of late systemic thromboembolism. In no instance has there been a need to close the fenestration.
Elective fenestration of the intraatrial baffle is associated with decreased Fontan failure rate and decreased occurrence of significant postoperative pleural effusions. Routine elective fenestration of the atrial baffle may, therefore, be justified in all univentricular repairs.
在采用挡板开窗术十年后，功能性单心室心脏的Fontan型修复结果终于看起来很有希望。我们的研究旨在评估开窗术对单心室修复结果的影响。
1988年1月至1997年12月，348例患者（104例三尖瓣闭锁，244例其他形态学诊断）在我们研究所接受了单心室修复。自1994年以来，所有患者（n = 126）均进行了心房挡板的常规开窗术。
Fontan总体失败率为14%（348例中的50例），包括45例早期死亡和5例Fontan手术失败后拆除手术。未进行开窗术是Fontan失败的唯一且高度显著的预测因素（风险比[RR] 3.3，95%置信区间[CI] 1.49至7.31，p = 0.002）。27%的患者出现了大量胸腔积液。发现心房挡板未开窗（RR 3.97，95% CI 2.17至7.26，p < 0.001）和主动脉阻断时间超过60分钟（RR 2.15，95% CI 1.3至3.5，p = 0.002）是显著的危险因素。随访时间为6至120个月（平均46.0 +/- 18.0个月）。有12例晚期死亡，5例患者失访。90个月时的精算生存率（Kaplan Meier法）为81% +/- 4%。258例患者（90%）在最后一次随访时纽约心脏协会心功能分级为I级。开窗组的血氧饱和度范围为85%至94%（平均89%）。30例患者（占26%）的开窗术在平均34个月的时间内自发关闭，且未发生晚期体循环血栓栓塞事件。在任何情况下都无需关闭开窗。
心房内挡板的选择性开窗术与Fontan失败率降低及术后大量胸腔积液发生率降低相关。因此，在所有单心室修复中常规进行心房挡板的选择性开窗术可能是合理的。
