Laks H, Ardehali A, Grant P W, Permut L, Aharon A, Kuhn M, Isabel-Jones J, Galindo A
Department of Surgery, UCLA Medical Center 90024-1741, USA.
Circulation. 1995 Jun 15;91(12):2943-7. doi: 10.1161/01.cir.91.12.2943.
A modification of the Fontan procedure with unidirectional cavopulmonary connection is described in which the superior vena cava (SVC) is connected to the left pulmonary artery (PA) and the inferior vena cava (IVC) is connected to the right PA via a lateral tunnel with a snare-controlled, adjustable atrial septal defect (ASD). This allows matching of the SVC and IVC flows with the lung of appropriate size. The obligatory left Glenn shunt provides an adequate arterial oxygen saturation, and the elevation in SVC pressure is well tolerated. The adjustable ASD allows selective decompression of the IVC that maintains cardiac output and reduces fluid accumulation in the serous cavities.
Since March 1992, we have performed this procedure in 18 patients. There were 17 children and 1 adult. Median age was 3 years and 9 months (range, 13 months to 36 years). Six patients had been staged with a previous bidirectional Glenn shunt. Preoperative cardiac catheterization revealed a PA pressure of 13 +/- 2 mm Hg and a transpulmonary gradient of 5 +/- 3 mm Hg. Ventricular function was satisfactory in all patients. At the completion of bypass, the pressures in the SVC and IVC were 16 +/- 4 mm Hg and 10 +/- 3 mm Hg, respectively (P < .01). The left atrial pressure was 6.0 +/- 3.0 mm Hg and the arterial O2 saturation on 100% oxygen was 93 +/- 3%. There was one death as a result of intractable atrial arrhythmias. The remaining 17 patients had a mean hospital stay of 9.7 days (6 to 18 days). The length of pleural drainage was 7 +/- 3 days. The ASD was adjusted in 11 patients before discharge. Oxygen saturation at discharge was 85.4 +/- 4%. Nine patients had repeat catheterization. The ASD was completely closed in 6 patients, an average of 2.5 months after surgery (range, 3 weeks to 5 months). After ASD closure, the arterial oxygen saturation was 96 +/- 3%, and the SVC and IVC pressures were both 13 +/- 3 mm Hg.
The Fontan procedure with unidirectional cavopulmonary connection and adjustable ASD has several advantages that may reduce mortality and morbidity for the high-risk Fontan candidate.
描述了一种采用单向腔肺连接的改良Fontan手术，即上腔静脉（SVC）与左肺动脉（PA）相连，下腔静脉（IVC）通过带有圈套器控制、可调节房间隔缺损（ASD）的侧隧道与右肺动脉相连。这使得上腔静脉和下腔静脉的血流能够与大小合适的肺相匹配。强制性的左Glenn分流可提供足够的动脉血氧饱和度，且上腔静脉压力升高可被良好耐受。可调节的房间隔缺损允许选择性地降低下腔静脉压力，从而维持心输出量并减少浆膜腔积液。
自1992年3月以来，我们对18例患者实施了该手术。其中有17名儿童和1名成人。中位年龄为3岁9个月（范围为13个月至36岁）。6例患者曾接受过双向Glenn分流分期手术。术前心脏导管检查显示肺动脉压力为13±2 mmHg，跨肺压差为5±3 mmHg。所有患者的心室功能均令人满意。体外循环结束时，上腔静脉和下腔静脉压力分别为16±4 mmHg和10±3 mmHg（P<.01）。左心房压力为6.0±3.0 mmHg，吸入100%氧气时动脉血氧饱和度为93±3%。有1例患者因顽固性房性心律失常死亡。其余17例患者的平均住院时间为9.7天（6至18天）。胸腔引流时间为7±3天。11例患者在出院前对房间隔缺损进行了调整。出院时的血氧饱和度为85.4±4%。9例患者接受了再次导管检查。6例患者的房间隔缺损完全闭合，平均在术后2.5个月（范围为3周至5个月）。房间隔缺损闭合后，动脉血氧饱和度为96±3%，上腔静脉和下腔静脉压力均为13±3 mmHg。
采用单向腔肺连接和可调节房间隔缺损的Fontan手术具有若干优势，可能会降低高危Fontan手术候选患者的死亡率和发病率。
