Matsuda H, Covino E, Hirose H, Nakano S, Kishimoto H, Miyamoto Y, Nishigaki K, Takano H, Ohtake S, Sakaki S
First Department of Surgery, Osaka University Medical School, Japan.
J Thorac Cardiovasc Surg. 1988 Aug;96(2):219-26.
Acute liver dysfunction was analyzed in 15 patients who received a modified Fontan operation for single ventricle in nine (atrial isomerism, seven) and tricuspid or mitral atresia in six. Nine patients had elevation of serum glutamic-pyruvic transaminase levels above 1000 U/L during the first week. As an analysis of postoperative liver function during the first week, the highest values of serum glutamic-pyruvic transaminase and total bilirubin and the lowest prothrombin time were scored from 0 to 4 within each parameter, and totaled to give a liver dysfunction score. The liver dysfunction score was 0 to 2 (no or trivial injury) in five patients, 3 to 5 (mild) in two, and 6 to 11 (moderate or severe) in eight (53.3%). The group operated on for single ventricle had a higher incidence (67%) of a liver dysfunction score of 6 or higher than the other group (33%). A multivariate analysis for the prediction of the liver dysfunction score mainly from early postoperative hemodynamics showed the highest correlation with cardiac index, followed by urine output, systolic arterial pressure, and central venous pressure. One patient required plasmapheresis. Four died early (less than 1 month); three of these had a liver dysfunction score of 6 or higher. Those with scores of 6 or above had higher serum glutamic-pyruvic transaminase levels at 1 month after operation than those with scores less than 5. In three patients (single ventricle), hepatic venous oxygen saturation was monitored and showed a marked decrease to below 20% with subsequent acute liver dysfunction. These results indicate that acute liver dysfunction appears to occur in patients with complex lesions after a modified Fontan operation from possible hepatic hypoperfusion and that low cardiac output may be more crucial than high central venous pressure alone.
对15例接受改良Fontan手术的患者的急性肝功能障碍进行了分析，其中9例为单心室（心房异构，7例），6例为三尖瓣或二尖瓣闭锁。9例患者在第一周内血清谷丙转氨酶水平升高至1000 U/L以上。作为术后第一周肝功能的分析，每个参数内血清谷丙转氨酶和总胆红素的最高值以及凝血酶原时间的最低值从0到4进行评分，并总计得出肝功能障碍评分。5例患者的肝功能障碍评分为0至2（无或轻度损伤），2例为3至5（轻度），8例（53.3%）为6至11（中度或重度）。接受单心室手术的组肝功能障碍评分为6或更高的发生率（67%）高于另一组（33%）。主要根据术后早期血流动力学预测肝功能障碍评分的多因素分析显示，与心脏指数的相关性最高，其次是尿量、收缩动脉压和中心静脉压。1例患者需要进行血浆置换。4例早期死亡（不到1个月）；其中3例肝功能障碍评分为6或更高。评分在6分及以上的患者术后1个月时血清谷丙转氨酶水平高于评分低于5分的患者。在3例（单心室）患者中监测了肝静脉血氧饱和度，结果显示随着随后急性肝功能障碍的出现，肝静脉血氧饱和度显著下降至20%以下。这些结果表明，改良Fontan手术后，复杂病变患者可能因肝脏灌注不足而出现急性肝功能障碍，低心输出量可能比单纯高中心静脉压更为关键。
