Stein D G, Laks H, Drinkwater D C, Permut L C, Louie H W, Pearl J M, George B L, Williams R G
Division of Cardiothoracic Surgery, UCLA School of Medicine.
J Thorac Cardiovasc Surg. 1991 Aug;102(2):280-6; discussion 286-7.
Total cavopulmonary connection was proposed as a modification of the Fontan procedure that might have greater benefits than previous methods. To assess this procedure we reviewed case histories of 38 patients (aged 17 months to 30 years) who underwent Fontan procedures with cavopulmonary anastomoses between January 1987 and December 1989. The group included 32 patients with univentricular heart, 2 with pulmonary atresia and intact ventricular septum, 3 with tricuspid atresia, and 1 with hypoplastic left heart syndrome. One or more previous palliative procedures were performed in 34 patients, including 19 systemic-pulmonary shunts, 16 pulmonary artery bandings, 7 atrial septectomies/septostomies, 7 Glenn shunts, and 1 patent ductus arteriosus ligation. Preoperative hemodynamics showed a pulmonary artery pressure of 12 mm Hg (range 6 to 22 mm Hg), pulmonary-systemic flow ratio of 1.6 (range 0.37 to 3.0), left ventricular end-diastolic pressure 9 mm Hg (range 3 to 15 mm Hg), and systemic arterial oxygen saturation of 82% (range 67% to 94%). Concomitant with cavopulmonary connection, 13 patients underwent additional procedures, including 9 atrioventricular valve annuloplasties, 4 Damus-Stansel-Kaye procedures, and 2 resections of subaortic membranes. Modifying the Fontan procedure in this fashion was particularly useful in the management of 2 patients with pulmonary atresia and intact ventricular septum who had right ventricular-dependent coronary blood flow. Cavopulmonary anastomosis and atrial septectomy were performed in both patients, with resultant inflow of oxygenated blood to the right ventricle and coronary arteries. Excellent postoperative results were noted in each. Postextubation hemodynamics for the entire group included a mean right atrial pressure of 13 mm Hg (range 11 to 17 mm Hg), a mean left atrial pressure of 6 mm Hg (range 3 to 12 mm Hg), and a room air oxygen saturation of 96% (range 92% to 98%). Seven patients had pleural effusions, 3 required postoperative pacemaker placement, and 2 required reoperation for tamponade. A venous assist device was required in one patient on the second postoperative day, but the patient was weaned successfully within 24 hours. One early death (2.6%) occurred in a patient who had intractable ventricular fibrillation 2 days after operation. There was one late cardiac death (2.7%) caused by ventricular failure and one late noncardiac death. These results demonstrate that total cavopulmonary connection provides excellent early definitive treatment, with low morbidity and mortality, for a variety of complex congenital heart lesions.
全腔静脉肺动脉连接术是作为Fontan手术的一种改良术式提出的，可能比以往方法具有更大的益处。为评估该手术，我们回顾了1987年1月至1989年12月期间接受Fontan手术并行腔静脉肺动脉吻合术的38例患者（年龄17个月至30岁）的病历。该组包括32例单心室心脏患者、2例肺动脉闭锁合并完整室间隔患者、3例三尖瓣闭锁患者和1例左心发育不全综合征患者。34例患者曾接受过一次或多次姑息性手术，包括19例体肺分流术、16例肺动脉环扎术、7例房间隔切除术/造口术、7例Glenn分流术和1例动脉导管未闭结扎术。术前血流动力学显示肺动脉压为12 mmHg（范围6至22 mmHg），肺循环与体循环血流量之比为1.6（范围0.37至3.0），左心室舒张末期压力为9 mmHg（范围3至15 mmHg），体动脉血氧饱和度为82%（范围67%至94%）。在进行腔静脉肺动脉连接术的同时，13例患者还接受了其他手术，包括9例房室瓣环成形术、4例Damus-Stansel-Kaye手术和2例主动脉下膜切除术。以这种方式改良Fontan手术对2例肺动脉闭锁合并完整室间隔且有右心室依赖型冠状动脉血流的患者的治疗特别有用。对这2例患者均进行了腔静脉肺动脉吻合术和房间隔切除术，结果含氧血流入右心室和冠状动脉。每例患者术后效果均良好。全组患者拔管后的血流动力学指标包括平均右心房压为13 mmHg（范围11至17 mmHg），平均左心房压为6 mmHg（范围3至12 mmHg），室内空气血氧饱和度为96%（范围92%至98%）。7例患者出现胸腔积液，3例术后需要放置起搏器，2例因心包填塞需要再次手术。1例患者术后第二天需要使用静脉辅助装置，但在24小时内成功撤机。1例患者术后2天出现顽固性心室颤动，早期死亡（2.6%）。有1例晚期心脏死亡（2.7%）由心室衰竭引起，1例晚期非心脏死亡。这些结果表明，全腔静脉肺动脉连接术为各种复杂先天性心脏病损提供了良好的早期确定性治疗，发病率和死亡率低。
