Adachi Iki, Yagihara Toshikatsu, Kagisaki Koji, Hagino Ikuo, Ishizaka Toru, Kobayashi Junjiro, Kitamura Soichiro, Uemura Hideki
Department of Cardiovascular Surgery, National Cardiovascular Center, Suita, Japan.
Eur J Cardiothorac Surg. 2007 Jul;32(1):156-62. doi: 10.1016/j.ejcts.2007.03.024. Epub 2007 May 21.
It was well discussed, in the primary Fontan era, that small pulmonary arterial size could affect the results immediately after the Fontan procedure. The objective of the present study is to determine whether this feature remains as a risk factor in the era of the staged Fontan completion and poses functional impediments in the longer terms.
Between June 1991 and November 2004, the staged Fontan completion was carried out subsequent to the bidirectional Glenn procedure in consecutive 57 patients with a preoperative pulmonary artery index less than 250 mm2/m2 (Group-S; minimum index 104 mm2/m2). Clinical data were reviewed retrospectively. As background and reference information, similar data were collected in another consecutive 64 patients with larger pulmonary arteries who underwent the staged Fontan completion during the same period (Group-L; maximum index 697 mm2/m2).
No patients died after the Fontan procedure in Group-S, while six early deaths in Group-L. No takedown of the Fontan circulation was carried out in either group. The latest catheterizations, at 2.8+/-2.7 years postoperatively, showed a pulmonary artery index significantly lower than the preoperative index (Group-S: 198+/-37-176+/-49 mm2/m2; P=0.0082, Group-L: 360+/-94-266+/-89 mm2/m2; P<0.0001). Hemodynamics in Group-S during the intermediate term were identical with those in Group-L in mean pulmonary arterial pressure (10+/-2 in Group-S and 10+/-3 mmHg in Group-L), mean atrial pressure for the systemic chambers (5+/-2 and 6+/-3 mmHg, respectively), mean transpulmonary gradient (5+/-2 and 4+/-2 mmHg, respectively), cardiac index (3.0+/-0.7 and 3.0+/-0.6l/min/m2, respectively), and arterial oxygen saturation (93+/-3% and 94+/-2%, respectively). Similarly, brain natriuretic peptides concentration in the serum (19.4+/-15.6 in Group-S and 28.3+/-37.2 pg/ml in Group-L) and peak oxygen consumption on exercise testing (24.8+/-4.5 and 24.0+/-6.3 ml/kg/min, respectively) were not inferior in Group-S to those in Group-L.
The outcome after the Fontan completion, including functional ones in the intermediate term, was acceptable in patients having a preoperative PA index smaller than 250 mm2/m2. Pulmonary artery index decreased still further postoperatively, but did not obviously militate against functional efficacy of the Fontan circulation.
在最初的Fontan手术时代，人们充分讨论了肺动脉管径较小可能会影响Fontan手术后的即刻效果。本研究的目的是确定在分期完成Fontan手术的时代，这一特征是否仍然是一个危险因素，并在长期内造成功能障碍。
在1991年6月至2004年11月期间，对连续57例术前肺动脉指数小于250mm²/m²的患者（S组；最小指数为104mm²/m²）在双向Glenn手术后进行分期Fontan手术。对临床数据进行回顾性分析。作为背景和参考信息，同期对另外64例肺动脉较大且接受分期Fontan手术的连续患者（L组；最大指数为697mm²/m²）收集了类似数据。
S组Fontan手术后无患者死亡，而L组有6例早期死亡。两组均未进行Fontan循环拆除。术后2.8±2.7年的最新导管检查显示，肺动脉指数显著低于术前指数（S组：198±37-176±49mm²/m²；P=0.0082，L组：360±94-266±89mm²/m²；P<0.0001）。S组中期的血流动力学与L组在平均肺动脉压（S组为10±2，L组为10±3mmHg）、体循环心房平均压（分别为5±2和6±3mmHg）、平均跨肺压差（分别为5±2和4±2mmHg）、心脏指数（分别为3.0±0.7和3.0±0.6l/min/m²）以及动脉血氧饱和度（分别为93±3%和94±2%）方面相同。同样，S组血清中的脑钠肽浓度（S组为19.4±15.6，L组为28.3±37.2pg/ml）和运动试验中的最大氧耗量（分别为24.8±4.5和24.0±6.3ml/kg/min）并不低于L组。
术前肺动脉指数小于250mm²/m²的患者，Fontan手术完成后的结果，包括中期的功能结果，是可以接受的。术后肺动脉指数进一步下降，但并未明显影响Fontan循环的功能疗效。
