Sughimoto Koichi, Matsuo Kozo, Niwa Koichiro, Kawasoe Yasutaka, Tateno Shigeru, Shirai Takeaki, Kabasawa Masashi, Ohba Masanao
1 Department of Cardiac Surgery, The Royal Children's Hospital, Melbourne, Australia.
2 Department of Cardiac Surgery, Chiba Cardiovascular Center, Ichihara, Japan.
Cardiol Young. 2014 Apr;24(2):290-6. doi: 10.1017/S1047951113000280. Epub 2013 Mar 27.
Despite the broadened indications for Fontan procedure, there are patients who could not proceed to Fontan procedure because of the strict Fontan criteria during the early period. Some patients suffer from post-Glenn complications such as hypoxia, arrhythmia, or fatigue with exertion long after the Glenn procedure. We explored the possibility of Fontan completion for those patients.
Between 2004 and 2010, five consecutive patients aged between 13 and 31 years (median 21) underwent Fontan completion. These patients had been followed up for more than 10 years (10 to 13, median 11) after Glenn procedure as non-Fontan candidates. We summarise these patients retrospectively in terms of their pre-operative physiological condition, surgical strategy, and problems that these patients hold.
Pre-operative catheterisation showed pulmonary vascular resistance ranging from 0.9 to 3.7 (median 2.2), pulmonary to systemic flow ratio of 0.3 to 1.6 (median 0.9), and two patients had significant aortopulmonary collaterals. Extracardiac total cavopulmonary connections were performed in three patients, lateral tunnel total cavopulmonary connection in one patient, and intracardiac total cavopulmonary connection in one patient, without a surgical fenestration. Concomitant surgeries were required including valve surgeries--atrioventricular valve plasty in three patients and tricuspid valve replacement in one patient; systemic outflow tract obstruction release--Damus-Kaye-Stansel procedure in two patients and subaortic stenosis resection in one patient; and anti-arrhythmic therapies--maze procedure in two patients, cryoablation in two patients, and pacemaker implantation in two patients. All patients are now in New York Heart Association category I.
Patients often suffer from post-Glenn complications. Of those, if they are re-examined carefully, some may have a chance to undergo Fontan completion and benefit from it. Multiple lesions such as atrioventricular valve regurgitation, systemic outflow obstruction, or arrhythmia should be surgically repaired concomitantly.
尽管Fontan手术的适应症有所拓宽，但仍有一些患者因早期严格的Fontan标准而无法进行该手术。一些患者在Glenn手术后很长时间仍遭受诸如缺氧、心律失常或劳力性疲劳等Glenn术后并发症。我们探讨了这些患者完成Fontan手术的可能性。
2004年至2010年期间，连续5例年龄在13至31岁（中位数21岁）的患者接受了Fontan手术完成治疗。这些患者在Glenn手术后作为非Fontan手术候选人接受了超过10年（10至13年，中位数11年）的随访。我们根据患者术前的生理状况、手术策略以及存在的问题对这些患者进行了回顾性总结。
术前心导管检查显示肺血管阻力为0.9至3.7（中位数2.2），肺循环与体循环血流量之比为0.3至1.6（中位数0.9），两名患者存在明显的主肺动脉侧支血管。3例患者进行了心外全腔静脉肺动脉连接术，1例患者进行了侧隧道全腔静脉肺动脉连接术，1例患者进行了心内全腔静脉肺动脉连接术，均未进行手术开窗。需要进行同期手术，包括瓣膜手术——3例患者进行了房室瓣成形术，1例患者进行了三尖瓣置换术；解除体循环流出道梗阻——2例患者进行了Damus-Kaye-Stansel手术，1例患者进行了主动脉瓣下狭窄切除术；抗心律失常治疗——2例患者进行了迷宫手术，2例患者进行了冷冻消融术，2例患者进行了起搏器植入术。所有患者目前均处于纽约心脏协会I级。
患者常遭受Glenn术后并发症。其中，如果对他们进行仔细复查，一些患者可能有机会完成Fontan手术并从中受益。诸如房室瓣反流、体循环流出道梗阻或心律失常等多种病变应在手术中同时修复。
