Kuhn M A, Jarmakani J M, Laks H, Alejos J C, Permut L C, Galindo A, Isabel-Jones J B
Division of Pediatric Cardiology, University of California Los Angeles, School of Medicine 90024, USA.
J Am Coll Cardiol. 1995 Jul;26(1):259-65. doi: 10.1016/0735-1097(95)00137-o.
The aim of this study was to evaluate prospectively the effect of late atrial septal defect closure on cardiac output and oxygen delivery in patients who have undergone the Fontan procedure.
An adjustable atrial septal defect is incorporated in patients undergoing the Fontan procedure who have increased pulmonary vascular resistance or poor ventricular function, or both. After the Fontan procedure, the atrial septal defect is test occluded. Patients with mean right atrial and pulmonary artery pressures > 15 mm Hg are discharged with the atrial septal defect open.
Twelve patients (20 months to 12 years old) underwent evaluation and closure of the atrial septal defect at a mean interval of 3.8 months (range 1 to 18) after the Fontan procedure. Each patient underwent full right and left heart catheterization. Cardiac output was obtained using the cine-volume method. The study included six patients with a high transpulmonary gradient or poor ventricular function preoperatively, or both (high risk group) and six who had only borderline increased pulmonary vascular resistance (low risk group). Patients in both groups had a mean right atrial pressure > 15 mm Hg when the atrial defect was test occluded in the first week after the Fontan procedure.
All results are given as mean value +/- SD. Ventricular end-diastolic pressure was significantly lower (p = 0.03) with the atrial septal defect open in low risk patients (6 +/- 3 mm Hg) than in high risk patients (10 +/- 3 mm Hg). With the atrial septal defect open, low risk patients had a significantly higher (p = 0.04) cardiac index (4.87 +/- 0.81 liters/min per m2) than the high risk patients (3.96 +/- 0.47 liters/min per m2). There was no significant difference (p = 0.14) in cardiac index between the two groups with occlusion of the atrial septal defect. Oxygen delivery was also significantly higher (p < 0.05) with the atrial septal defect open in low risk patients (836 +/- 99 ml/min per m2) than in high risk patients (704 +/- 106 ml/min per m2). There was no significant difference (p = 0.89) in oxygen delivery between the two groups with occlusion of the atrial septal defect. With the atrial septal defect open, the interatrial gradient was not significantly different in low risk patients (4 +/- 1 mm Hg) from that in high risk patients (4 +/- 1 mm Hg).
These data show that an interatrial communication results in increased postoperative systemic perfusion and oxygen delivery in patients with good diastolic ventricular function after the Fontan procedure.
本研究旨在前瞻性评估晚期房间隔缺损封堵术对接受Fontan手术患者的心输出量和氧输送的影响。
在接受Fontan手术的患者中，如果存在肺血管阻力增加或心室功能不良，或两者兼而有之，则会植入一个可调节的房间隔缺损。Fontan手术后，对房间隔缺损进行试验性封堵。平均右心房和肺动脉压>15 mmHg的患者在房间隔缺损开放的情况下出院。
12例患者（年龄20个月至12岁）在Fontan手术后平均3.8个月（范围1至18个月）接受了房间隔缺损的评估和封堵。每位患者均接受了完整的右心和左心导管检查。采用电影容积法获得心输出量。该研究包括6例术前经肺梯度高或心室功能不良，或两者兼有的患者（高风险组）和6例仅肺血管阻力临界升高的患者（低风险组）。两组患者在Fontan手术后第一周试验性封堵房间隔缺损时，平均右心房压均>15 mmHg。
所有结果均以平均值±标准差表示。低风险患者（6±3 mmHg）房间隔缺损开放时的心室舒张末期压力显著低于高风险患者（10±3 mmHg）（p = 0.03）。房间隔缺损开放时，低风险患者的心指数（4.87±0.81升/分钟每平方米）显著高于高风险患者（3.96±0.47升/分钟每平方米）（p = 0.04）。房间隔缺损封堵时，两组的心指数无显著差异（p = 0.14）。低风险患者（836±99毫升/分钟每平方米）房间隔缺损开放时的氧输送也显著高于高风险患者（704±106毫升/分钟每平方米）（p < 0.05）。房间隔缺损封堵时，两组的氧输送无显著差异（p = 0.89）。房间隔缺损开放时，低风险患者（4±1 mmHg）与高风险患者（4±1 mmHg）的房压差无显著差异。
这些数据表明，房间隔交通可使Fontan手术后舒张期心室功能良好的患者术后全身灌注和氧输送增加。
