Mott Antonio R, Feltes Timothy F, McKenzie E Dean, Andropoulos Dean B, Bezold Louis I, Fenrich Arnold L, Bedford Shannon L, El-Said Howaida, Stayer Stephen A, Fraser Charles D
Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston 77030, USA.
Ann Thorac Surg. 2004 Apr;77(4):1334-40. doi: 10.1016/j.athoracsur.2003.10.011.
A growing number of adults with functional single ventricles are presenting as candidates for first-time and redo-Fontan operations. This study describes the clinical presentation and early operative results of adults who have undergone Fontan modifications.
Between July 1995 and April 2003, 23 patients (>18 years old) had Fontan operations. We retrospectively reviewed their perioperative courses.
Twenty-three Fontan operations (first-time [n = 8] and redo [n = 15]) were performed with no early or late deaths. No patient has required reoperation. One patient has been listed for orthotopic heart transplantation. The overall mean age is 23 years (18 to 41 years); mean follow-up, 30 months; median postoperative hospital stay, 8 days (4 to 34 days); and median duration of chest tube drainage, 4 days (2 to 12 days). The postoperative New York Heart Association (NYHA) functional class was improved in 22 of 23 patients. Eight first-time Fontan operations (7 of 8 nonfenestrated) were performed; lateral tunnel (n = 7) and extracardiac conduit (n = 1). Two patients had preoperative arrhythmias. New onset arrhythmias (ventricular tachycardia and sinus node dysfunction), requiring treatment, occurred in two patients. Fifteen redo-Fontan operations (all nonfenestrated) were performed; lateral tunnel (n = 5) and extracardiac conduit (n = 10). Fifteen patients had preoperative arrhythmias, thirteen of which had intraatrial reentry tachycardia (IART) and required antiarrhythmic medications. Concomitant intraoperative radiofrequency ablation (RFA) (n = 11) and cryoablation (n = 1) procedures were performed. In the immediate postoperative period, there was IART recurrence in five patients (post-RFA [n = 4] and postcryoablation [n = 1]). At latest follow-up, no patient is being treated with antiarrhythmic medications. Two patients had new onset atrial arrhythmias that required treatment.
The Fontan operation can be performed in adults with minimal morbidity and improved NYHA functional class. New onset arrhythmias requiring treatment are sources of perioperative morbidity. Complete arrhythmia resolution of the preoperative arrhythmia may not be achieved in the immediate postoperative period in redo-Fontan patients. However, modification (intraoperative radiofrequency ablation-right atrial debulking) of the atrial tachycardia circuits in the redo-Fontan patients can result in complete resolution of preoperative atrial tachyarrhythmias at early follow-up.
越来越多患有功能性单心室的成年人成为首次和再次进行Fontan手术的候选者。本研究描述了接受Fontan手术改良的成年人的临床表现和早期手术结果。
1995年7月至2003年4月期间，23例（年龄>18岁）患者接受了Fontan手术。我们回顾性分析了他们的围手术期过程。
共进行了23例Fontan手术（首次手术[n = 8]和再次手术[n = 15]），无早期或晚期死亡病例。没有患者需要再次手术。有1例患者已被列入原位心脏移植名单。总体平均年龄为23岁（18至41岁）；平均随访时间为30个月；术后住院时间中位数为8天（4至34天）；胸管引流时间中位数为4天（2至12天）。23例患者中有22例术后纽约心脏协会（NYHA）心功能分级得到改善。进行了8例首次Fontan手术（8例非开窗手术中的7例）；侧隧道手术（n = 7）和心外管道手术（n = 1）。2例患者术前有心律失常。2例患者出现需要治疗的新发心律失常（室性心动过速和窦房结功能障碍）。进行了15例再次Fontan手术（均为非开窗手术）；侧隧道手术（n = 5）和心外管道手术（n = 10）。15例患者术前有心律失常，其中13例有房内折返性心动过速（IART），需要抗心律失常药物治疗。术中同时进行了射频消融（RFA）（n = 11）和冷冻消融（n = 1）。术后即刻，5例患者出现IART复发（射频消融后[n = 4]和冷冻消融后[n = 1]）。在最近一次随访时，没有患者接受抗心律失常药物治疗。2例患者出现需要治疗的新发房性心律失常。
Fontan手术可在成年人中进行，并发症发生率低，NYHA心功能分级得到改善。需要治疗的新发心律失常是围手术期并发症的来源。再次Fontan手术患者术后即刻可能无法完全消除术前心律失常。然而，对再次Fontan手术患者的房性心动过速环路进行改良（术中射频消融 - 右心房减容）可在早期随访时使术前房性快速心律失常完全消除。
