Saito S, Imai Y, Takanashi Y, Aoki M, Hoshino S, Nakata S, Terada M, Shinozaki M
Department of Pediatric Cardiovascular Surgery, Tokyo Women's Medical College, Japan.
Nihon Kyobu Geka Gakkai Zasshi. 1995 Sep;43(9):1631-8.
We examined our surgical experiences to determine the appropriate condition of pulmonary artery banding (PAB) for the Fontan procedure. From 1974 through 1992, thirteen patients underwent Fontan procedure following PAB at Tokyo Women's Medical College. Of these 6 had tricuspid atresia (TA), 5 had single ventricle, or 2 had other complex malformations. PAB was performed at the age of 1 to 14 months (mean 2.5 months). With monitoring pulmonary artery (PA) pressure and systemic arterial oxygen tension (PaO2), PA mean pressure decreased 43.6 to 18.8 mmHg and PA circumferences at the banding site decreased from 53.5 to 26.0 mm after PAB. This degree of PAB was tighter compared with the value estimated by Trusler's formula (27.9 mm) in most patients. After PAB, 5 patients required 8 additional palliative surgery including 3 systemic to pulmonary shunt, 3 rebanding, 1 palliative RVOTR to promote development of pulmonary vascular bed and 1 atrial septectomy to prevent pulmonary hypertension. Hemodynamic data before Fontan operation showed a tendency of higher PA pressure (17.5 vs 31.5 mmHg), and pulmonary vascular resistance (2.4 vs 5.5 Wood Unit) in non-survivors than in survivors. For patients with tricuspid atresia and high pulmonary vascular resistance, a new operation "Anatomical Repair" utilizing hypoplastic right ventricle with the translocation of pulmonary or aortic valve in tricuspid position was developed and successfully applied in three patients. In conclusion, initial tight PAB during early infancy and often repeated palliative surgery for development of adequate pulmonary vascular bed is the most important for maximizing the chance of subsequent successful Fontan procedure.
我们回顾了我们的手术经验，以确定用于Fontan手术的肺动脉环扎术（PAB）的合适条件。1974年至1992年期间，东京女子医科大学有13例患者在肺动脉环扎术后接受了Fontan手术。其中6例患有三尖瓣闭锁（TA），5例患有单心室，2例患有其他复杂畸形。肺动脉环扎术在1至14个月龄（平均2.5个月）时进行。通过监测肺动脉（PA）压力和体动脉血氧张力（PaO2），肺动脉平均压力在肺动脉环扎术后从43.6 mmHg降至18.8 mmHg，环扎部位的肺动脉周长从53.5 mm降至26.0 mm。在大多数患者中，这种程度的肺动脉环扎术比Trusler公式估计的值（27.9 mm）更紧。肺动脉环扎术后，5例患者需要额外进行8次姑息性手术，包括3次体肺分流术、3次再次环扎术、1次姑息性右心室流出道重建术以促进肺血管床发育以及1次房间隔切除术以预防肺动脉高压。Fontan手术前的血流动力学数据显示，非存活者的肺动脉压力（17.5 vs 31.5 mmHg）和肺血管阻力（2.4 vs 5.5 Wood单位）有高于存活者的趋势。对于三尖瓣闭锁和肺血管阻力高的患者，一种利用发育不良的右心室并将肺动脉瓣或主动脉瓣移位至三尖瓣位置的新手术“解剖修复”被开发出来，并成功应用于3例患者。总之，婴儿早期进行初始紧密的肺动脉环扎术以及经常重复进行姑息性手术以促进足够的肺血管床发育，对于最大限度地提高后续Fontan手术成功的机会最为重要。
