Amodeo Antonio, Grigioni Mauro, Filippelli Sergio, Gagliardi Maria Giulia, Del Gaudio Costantino, Morbiducci Umberto, D'Avenio Giuseppe, Brancaccio Gianluca, Di Donato Roberto M
Cardiac Surgery Service of the Medical-Surgical Department of Paediatric Cardiology, Bambino Gesù Paediatric Hospital, Piazza S. Onofrio 4, Rome, Italy.
J Thorac Cardiovasc Surg. 2009 Nov;138(5):1154-9. doi: 10.1016/j.jtcvs.2009.04.039. Epub 2009 Jul 10.
Two innovative surgical approaches addressing systemic venous anomalies in single-ventricle patients are evaluated.
Between 2003 and 2007, 7 patients underwent a unifocal bilateral bidirectional cavopulmonary anastomosis, and 5 patients underwent a hepatoazygos venous connection associated with a previous (n = 4) or concomitant (n = 1) Kawashima operation. Computational fluid dynamics simulations allowed investigation of 2 sets of comparative models: (1) bifocal versus unifocal bilateral bidirectional cavopulmonary anastomosis and (2) classic hepatic vein-pulmonary artery channel versus hepatoazygos direct anastomosis for Fontan completion after or combined with the Kawashima operation.
There was 1 hospital death in the unifocal bilateral bidirectional cavopulmonary anastomosis group. At a mean follow-up of 15.6 +/- 7.40 months after a unifocal bilateral bidirectional cavopulmonary anastomosis and of 38.7 +/- 13.2 months after direct hepatoazygos venous connection, respectively, all 11 survivors are in New York Heart Association class I with functional anastomoses. Computational assessment of bifocal bilateral bidirectional cavopulmonary anastomosis demonstrated weak perfusion between caval veins against symmetric and steady bilateral flow fields in the unifocal arrangement. In the classic post-Kawashima Fontan completion model, the hepatic venous flow to the pulmonary artery was held back by means of preponderant opposite flow, whereas in the direct hepatoazygos venous connection model, the hepatic venous flow merged smoothly into the azygos vein. Power-loss calculation showed no significant difference between bifocal and unifocal bilateral bidirectional cavopulmonary anastomosis topology, whereas the hepatoazygos connection clearly had better energy preservation than the classical connection.
This limited clinical and computational fluid dynamics assessment suggests the efficacy of this new rationale to reduce the additional thrombotic risks produced by systemic venous anomalies in single-ventricle patients.
评估两种针对单心室患者系统性静脉异常的创新手术方法。
2003年至2007年间，7例患者接受了单灶双侧双向腔肺吻合术，5例患者接受了与先前（n = 4）或同期（n = 1）川岛手术相关的肝奇静脉连接术。计算流体动力学模拟允许研究两组对比模型：（1）双灶与单灶双侧双向腔肺吻合术；（2）经典肝静脉-肺动脉通道与肝奇静脉直接吻合术用于川岛手术后或与川岛手术联合后的Fontan完成术。
单灶双侧双向腔肺吻合术组有1例院内死亡。单灶双侧双向腔肺吻合术后平均随访15.6± /- 7.40个月，肝奇静脉直接连接术后平均随访38.7± /- 13.2个月，所有11名幸存者均为纽约心脏协会I级，吻合口功能良好。双灶双侧双向腔肺吻合术的计算评估显示，在单灶布局中对称且稳定的双侧流场情况下，腔静脉之间的灌注较弱。在经典的川岛手术后Fontan完成模型中，肝静脉向肺动脉的血流因优势反向血流而受阻，而在肝奇静脉直接连接模型中，肝静脉血流顺利汇入奇静脉。功率损失计算显示双灶和单灶双侧双向腔肺吻合术拓扑结构之间无显著差异，而肝奇静脉连接明显比经典连接具有更好的能量保存。
这种有限的临床和计算流体动力学评估表明，这种新原理对于降低单心室患者系统性静脉异常产生的额外血栓形成风险是有效的。
