Yagihara T, Yamamoto F, Nishigaki K, Matsuki O, Uemura H, Isizaka T, Takahashi O, Kamiya T, Kawashima Y
Department of Cardiovascular Surgery, National Cardiovascular Center, Osaka, Japan.
J Thorac Cardiovasc Surg. 1996 Aug;112(2):392-402. doi: 10.1016/s0022-5223(96)70267-2.
To extend the indications for corrective operation in patients with pulmonary atresia, ventricular septal defect, and major aortopulmonary collateral arteries, surgical procedures were done to unify the blood sources for pulmonary perfusion. Since December 1985, 50 patients have undergone unifocalization at ages from 2 months to 26 years with a mean of 6 +/- 7 years. In total, 84 staged unifocalization procedures and 5 other palliative procedures were done in 49 patients. These included several operative procedures: simple ligation of major aortopulmonary collateral arteries in 8; pulmonary angioplasty in 29 including reconstruction of the pulmonary arterial tree by direct anastomosis or interposition between the central pulmonary arteries and the intrapulmonary arteries; construction of artificial central pulmonary arteries with use of a xenograft pericardial tube graft in 36 with no native central pulmonary arteries detected; and construction of supplemental central pulmonary arteries also with use of a pericardial tube graft in 10. The pericardial tube graft, if used, was anastomosed to the intrapulmonary arteries on one end and connected to a prosthetic tube on the other end so as to perfuse the reconstructed pulmonary arteries. The anastomosis was made inside the lung through the divided interlobar fissure. Five patients died after operation among those undergoing these 89 preparative operative procedures. Deaths were related either to bleeding caused by anticoagulation therapy administered to prevent thrombosis within the xenograft pericardial tube graft used or to progressive congestive heart failure as a result of an excessive amount of pulmonary blood flow. Twenty-six patients have undergone intracardiac repair after previous unifocalization. In 16 patients the artificial central pulmonary arteries surgically constructed were connected to each other and then an external conduit was placed. In another patient, intracardiac repair and unifocalization could be concomitantly achieved via a median sternotomy. The right ventricle to left ventricle systolic pressure ratio immediately after intracardiac repair in 27 patients ranged from 0.24 to 0.91 with a mean of 0.54 +/- 0.17. One patient (4%) died shortly after intracardiac repair because of thrombosis within the pulmonary arteries. Postoperative catheterization showed that pulmonary vascular resistance was correlated significantly with the number of pulmonary vascular segments functioning rather than with the condition of the central pulmonary arteries. We conclude that surgical unifocalization is a feasible procedure before subsequent intracardiac repair, even in patients with critically hypoplastic or absent central pulmonary arteries.
为扩大肺动脉闭锁、室间隔缺损及主要体肺侧支动脉患者矫正手术的适应证，实施了手术操作以统一肺灌注的血源。自1985年12月以来，50例年龄从2个月至26岁（平均6±7岁）的患者接受了单源化手术。49例患者共进行了84次分期单源化手术及5次其他姑息性手术。这些手术包括几种术式：8例单纯结扎主要体肺侧支动脉；29例进行肺血管成形术，包括通过直接吻合或在中央肺动脉与肺内动脉之间植入血管来重建肺动脉树；36例未检测到原生中央肺动脉，使用异种心包管移植构建人工中央肺动脉；10例同样使用心包管移植构建补充中央肺动脉。心包管移植若使用，一端与肺内动脉吻合，另一端与人工血管连接，以便灌注重建的肺动脉。吻合在肺内通过分开的叶间裂进行。在这89例术前手术操作中，5例患者术后死亡。死亡原因要么是为防止在使用的异种心包管移植内形成血栓而进行抗凝治疗导致的出血，要么是肺血流量过多引起的进行性充血性心力衰竭。26例患者在先前的单源化手术后接受了心内修复。16例患者中，手术构建的人工中央肺动脉相互连接，然后放置一根外部管道。在另一例患者中，通过正中胸骨切开术可同时实现心内修复和单源化。27例患者心内修复后即刻右心室与左心室收缩压比值在0.24至0.91之间，平均为0.54±0.17。1例患者（4%）在心内修复后不久因肺动脉内血栓形成死亡。术后心导管检查显示，肺血管阻力与功能正常的肺血管节段数量显著相关，而非与中央肺动脉状况相关。我们得出结论，即使对于中央肺动脉严重发育不良或缺如的患者，手术单源化也是后续心内修复前可行的手术。
