Mavroudis Constantine, Deal Barbara J, Backer Carl L, Stewart Robert D, Franklin Wayne H, Tsao Sabrina, Ward Kendra M, DeFreitas R Andrew
Division of Cardiovascular Thoracic Surgery, Children's Memorial Hospital, Northwestern University, Chicago Illinois 60614, USA.
Ann Thorac Surg. 2007 Nov;84(5):1457-65; discussion 1465-6. doi: 10.1016/j.athoracsur.2007.06.079.
The evolving operative strategy and course of 111 consecutive Fontan conversions with arrhythmia surgery and pacemaker therapy were reviewed to identify risk factors for poor outcome.
Since 1994, 111 patients (mean age 22.5 +/- 7.9 years) underwent Fontan conversion with arrhythmia surgery. The series was divided into three time periods: (1) 1994 to 1996 (initial isthmus ablation, n = 9, group I); (2) 1996 to 2003 (early modified right atrial maze and Cox-maze III, n = 51, group II); and (3) 2003 to 2006 (recent modifications of the modified right atrial maze and left atrial Cox-maze III for both atrial fibrillation and left atrial reentry tachycardia, n = 51, group III).
There were one early (0.9%) and six late deaths (5.4%); six patients required cardiac transplantation (5.4%). Two late deaths occurred after transplantation. Renal failure requiring dialysis occurred in four patients (3.6%). Mean hospital stay was 13.7 +/- 12.1 days. Mean cross-clamp time was 70.8 +/- 41.6 minutes. Four risk factors for death or transplantation were identified: presence of a right or ambiguous ventricle, preoperative protein-losing enteropathy, preoperative moderate-to-severe atrioventricular valve regurgitation, and long (>239 minutes) cardiopulmonary bypass time. In intergroup comparisons (groups I and II versus group III), three trends were noted: increased incidence of concomitant surgical repairs (p = 0.03), older patients (p = 0.01), and increased incidence of left atrial reentry tachycardia and atrial fibrillation (p = 0.04). Late recurrence of atrial tachycardia ensued in 15 of 111 (13.5%); 8 of 51 in group II (15.7%) and 4 of 51 in group III (7.8) (p = 0.3).
Fontan conversion with arrhythmia surgery is safe and efficacious. Based on improved results and evolving surgical techniques, selection criteria can be more clearly defined.
回顾了111例连续进行的Fontan转换术联合心律失常手术及起搏器治疗的手术策略演变及病程，以确定预后不良的危险因素。
自1994年以来，111例患者（平均年龄22.5±7.9岁）接受了Fontan转换术联合心律失常手术。该系列分为三个时间段：（1）1994年至1996年（初始峡部消融，n = 9，第一组）；（2）1996年至2003年（早期改良右房迷宫和Cox迷宫III，n = 51，第二组）；以及（3）2003年至2006年（针对房颤和左房折返性心动过速对改良右房迷宫和左房Cox迷宫III的近期改良，n = 51，第三组）。
有1例早期死亡（0.9%）和6例晚期死亡（5.4%）；6例患者需要心脏移植（5.4%）。2例晚期死亡发生在移植后。4例患者（3.6%）出现需要透析的肾衰竭。平均住院时间为13.7±12.1天。平均阻断时间为70.8±41.6分钟。确定了4个死亡或移植的危险因素：存在右心室或不明确心室、术前蛋白丢失性肠病、术前中重度房室瓣反流以及长时间（>239分钟）体外循环时间。在组间比较（第一组和第二组与第三组）中，注意到三个趋势：同期手术修复发生率增加（p = 0.03）、患者年龄较大（p = 0.01）以及左房折返性心动过速和房颤发生率增加（p = 0.04）。111例中有15例（13.5%）出现房性心动过速晚期复发；第二组51例中有8例（15.7%），第三组51例中有4例（7.8%）（p = 0.3）。
Fontan转换术联合心律失常手术是安全有效的。基于改善的结果和不断发展的手术技术，可以更明确地界定选择标准。
