Department of Cardiothoracic Surgery, Children’s Memorial Health Institute, Warsaw, Poland.
Kardiol Pol. 2013;71(6):581-7. doi: 10.5603/KP.2013.0121.
A Fontan-type operation, i.e. a connection of the systemic veins and pulmonary arteries without subpulmonary ventricle, with different surgical techniques, is nowadays the only treatment option for patients with a functionally univentricular heart (UVH). Understanding the development of pulmonary arteries in patients who are considered for the Fontan procedure is important clinically.
To evaluate the development of pulmonary arteries in patients with univentricular circulation.
Between 1995 and 2007, 111 patients underwent a bidirectional Glenn procedure. In all patients, preoperative catheterisation was performed to assess the anatomy and haemodynamics of UVH, especially the size of the pulmonary arteries. Ninety nine patients were included in the bidirectional Glenn group; 62 of these underwent repeat catheterisation before Fontan completion. The late results, after one stage extracardiac total cavopulmonary anastomosis performed in 24 patients between 1992 and 2002, were reinvestigated (one-stage Fontan group). We assessed the changes in the McGoon ratio and Nakata index for the whole cohort of patients. McGoon ratio is the sum of the diameter of pulmonary arteries divided by the diameter of the aorta. Nakata index is the sum of the cross-sectional area of the pulmonary arteries divided by the body surface area.
During cardiac catheterisation prior to Glenn procedure, the mean Nakata index was 351.9 (range 131.2-886) mm2/m2 and was higher in patients with increased pulmonary flow (p = 0.0135). Mean McGoon ratio was 2.5 (range 1.1-4.9). An average 40.3 months after Glenn procedure, the Nakata index and McGoon ratio decreased significantly to 226.4 ± 125 mm²/m² (p < 0.003), and to 2.14 ± 0.58 (p < 0.008) respectively. In the group of patients after one-stage Fontan in late follow-up, mean 7.4 years after procedure, the Nakata index decreased from 318.7 ± 159.1 mm²/m² to 120 ± 40 mm²/m² (p < 0.0001) and McGoon ratio from 2.4 ± 0.6 to 1.4 ± 0.27 (p < 0.0001). Only size of pulmonary arteries before Glenn procedure, in the bidirectional Glenn group, or before Fontan operation, in the one-stage Fontan group,were inversely correlated with the changes of size of pulmonary arteries (p = 0.0015 and p = 0.0012).
The relative decrease of the size of pulmonary arteries in the inter-stage period (between bidirectional Glenn anastomosis and Fontan completion) and after Fontan completion may indicate that pulmonary artery sizes should probably not bean absolute limiting factor in the decision on treatment of functionally UVH patients, especially at the stage of Fontan approach.
Fontan 型手术，即没有亚肺动脉下心室的体循环静脉和肺动脉的连接，采用不同的手术技术，是目前功能性单心室（UVH）患者的唯一治疗选择。了解考虑 Fontan 手术患者的肺动脉发育情况在临床上很重要。
评估单心室循环患者的肺动脉发育情况。
1995 年至 2007 年间，111 例患者接受了双向 Glenn 手术。所有患者均行术前导管检查，以评估 UVH 的解剖结构和血流动力学，特别是肺动脉的大小。99 例患者纳入双向 Glenn 组；其中 62 例在 Fontan 完成前接受重复导管检查。2002 年之前，24 例患者接受了一期体外心肺旁路吻合术（一期 Fontan 组），我们对 24 例患者的术后结果进行了再调查。我们评估了整个患者队列的 McGoon 比值和 Nakata 指数的变化。McGoon 比值是肺动脉直径之和除以主动脉直径。Nakata 指数是肺动脉横截面积之和除以体表面积。
在 Glenn 手术前的心脏导管检查中，平均 Nakata 指数为 351.9（范围 131.2-886）mm2/m2，在肺动脉流量增加的患者中更高（p = 0.0135）。平均 McGoon 比值为 2.5（范围 1.1-4.9）。在 Glenn 手术后平均 40.3 个月，Nakata 指数和 McGoon 比值显著下降至 226.4±125mm²/m²（p<0.003）和 2.14±0.58（p<0.008）。在一期 Fontan 术后晚期随访的患者中，术后平均 7.4 年，Nakata 指数从 318.7±159.1mm²/m²降至 120±40mm²/m²（p<0.0001），McGoon 比值从 2.4±0.6 降至 1.4±0.27（p<0.0001）。只有双向 Glenn 组中 Glenn 术前、一期 Fontan 组中 Fontan 术前肺动脉的大小与肺动脉大小的变化呈负相关（p=0.0015 和 p=0.0012）。
在 Glenn 吻合术和 Fontan 完成之间的中间阶段（双向 Glenn 吻合术和 Fontan 完成之间）以及 Fontan 完成后的相对肺动脉大小下降可能表明，肺动脉大小在决定功能性 UVH 患者的治疗方法时可能不是绝对的限制因素，尤其是在 Fontan 治疗阶段。
