Salvin Joshua W, Scheurer Mark A, Laussen Peter C, Mayer John E, Del Nido Pedro J, Pigula Frank A, Bacha Emile A, Thiagarajan Ravi R
MPH, Department of Cardiology, Cardiac ICU Office, Bader 600, Children's Hospital Boston, 300 Longwood Avenue, Boston, MA 02115, USA.
Circulation. 2008 Sep 30;118(14 Suppl):S171-6. doi: 10.1161/CIRCULATIONAHA.107.750596.
Mortality and major morbidity after the Fontan operation is low in the current era. However, factors contributing to prolonged postoperative recovery are not clearly understood.
Data on all patients admitted to the cardiac intensive care unit (CICU) after a Fontan operation between June 2001 and December 2005 were retrospectively analyzed. We excluded all patients who died, required Fontan takedown, or required ECMO. The study cohort was further divided into a prolonged recovery group that included patients with >75%ile for duration of mechanical ventilation or pleural drainage, and a standard recovery group which included all other patients. A multivariable logistic regression model was used to compare demographic, anatomic, and physiological variables between the prolonged and standard recovery groups. There were 226 Fontan operations performed. Of the study population (n=218), the median age was 2.61 years (1.0 to 31.9 years) and weight was 12.45 kg (8.4 to 77.5 kg). The most common diagnosis was hypoplastic left heart syndrome (n=80, 36.7%). A systemic right atrioventricular valve was present in 139 (63.7%). The lateral tunnel fenestrated Fontan was the most common surgery (n=195, 89.4%). Within the study population, 81 (38%) patients meet criteria for prolonged recovery. Univariate risk factors for prolonged recovery included higher preoperative PVR (P=0.033), longer bypass times (P=0.009), higher postbypass lactate level (P=0.017), higher postoperative central venous (P<0.001) common atrial pressure (P=0.042), inotropic score (P<0.001), and need for greater volume resuscitation during the 24 postoperative hours (>75% for the entire group; P<0.001). In a multivariable model, need for greater volume resuscitation (OR 2.81, 95% CI 1.30, 6.05) was the only independent risk factor for prolonged outcome after the Fontan operation.
High volume expansion in the early postoperative period is an independent risk factor for prolonged recovery. The need for high volume expansion may represent the compound effects of multiple risk factors including preoperative hemodynamics and a marked systemic inflammatory response to surgery and cardiopulmonary bypass, which in turn may mediate prolonged recovery.
在当前时代，Fontan手术后的死亡率和主要并发症发生率较低。然而，导致术后恢复时间延长的因素尚不清楚。
对2001年6月至2005年12月期间接受Fontan手术后入住心脏重症监护病房（CICU）的所有患者的数据进行回顾性分析。我们排除了所有死亡、需要拆除Fontan手术或需要体外膜肺氧合（ECMO）的患者。研究队列进一步分为延长恢复组，包括机械通气或胸腔引流持续时间超过第75百分位数的患者，以及标准恢复组，包括所有其他患者。使用多变量逻辑回归模型比较延长恢复组和标准恢复组之间的人口统计学、解剖学和生理学变量。共进行了226例Fontan手术。在研究人群（n = 218）中，中位年龄为2.61岁（1.0至31.9岁），体重为12.45 kg（8.4至77.5 kg）。最常见的诊断是左心发育不全综合征（n = 80，36.7%）。139例（63.7%）存在体循环右房室瓣。侧隧道开窗Fontan手术是最常见的手术方式（n = 195，89.4%）。在研究人群中，81例（38%）患者符合延长恢复的标准。延长恢复的单因素危险因素包括术前肺血管阻力较高（P = 0.033）、体外循环时间较长（P = 0.009）、体外循环后乳酸水平较高（P = 0.017）、术后中心静脉（P < 0.001）和共同心房压力较高（P = 0.042）、血管活性药物评分较高（P < 0.001）以及术后24小时内需要更多的容量复苏（整个组中>75%；P < 0.001）。在多变量模型中，需要更多的容量复苏（比值比2.81，95%可信区间1.30，6.05）是Fontan手术后延长恢复的唯一独立危险因素。
术后早期大量扩容是延长恢复的独立危险因素。大量扩容的需求可能代表了多种危险因素的复合效应包括术前血流动力学以及对手术和体外循环的明显全身炎症反应，这反过来可能介导恢复时间延长。
