Gundry S R, Razzouk A J, del Rio M J, Shirali G, Bailey L L
Department of Surgery, Loma Linda University Medical Center, Calif, USA.
J Thorac Cardiovasc Surg. 1997 Oct;114(4):552-8; discussion 558-9. doi: 10.1016/S0022-5223(97)70043-6.
The concept of a lateral tunnel for the Fontan operation is now widely accepted. Most lateral tunnels are constructed intraatrially with the use of aortic crossclamping. Construction of extracardiac lateral tunnels with the use of homografts or other nonviable tubes eliminates aortic crossclamping but lacks growth potential in length or width. The native pericardium, which is "sealed" posteriorly along the pulmonary artery, atrium, and inferior vena cava, could be turned down onto the right atrium to form a viable extracardiac lateral tunnel.
We designed and successfully constructed extracardiac lateral tunnels using viable autologous pericardium, pedicled on its lateral blood supply, in 19 patients aged 9 months to 5 years. All patients had a previous Glenn shunt; five patients had dextrocardia and a midline inferior vena cava. The patients' inferior vena cava-right atrial connection was opened transversely and the right atrial opening was sutured to its back wall, keeping the eustachian valve in the inferior vena cava. The underside of the right pulmonary artery was opened longitudinally; its inferior edge was sewn to the adjacent pericardial reflection. Any "pocket" or depressions in the posterior pericardium along the pulmonary veins were closed with running suture. Two incisions were made in the right pericardium down to the phrenic nerve parallel to the inferior vena caval and pulmonary arterial openings. This pedicled pericardium was trimmed and sewn as a roof to the upper edges of the inferior vena cava and pulmonary artery openings and then sewn longitudinally along the unopened right atrial wall, completing the viable extracardiac lateral tunnel. Although no fenestrations were used, these could be made during construction, or more significantly, owing to the lack of thick walled structures, in the catheterization laboratory in the postoperative period.
All 19 patients had respiratory/cardiac pulsations in the pulmonary arteries owing to the compressible lateral tunnel. At follow-up of up to 2 1/2 years, all tunnels are growing and no obstructions have occurred.
The viable autologous pericardial extracardiac lateral tunnel can be constructed without cardiac ischemia, can be fenestrated in the postoperative period, and forms a compressible, nonthrombogenic conduit capable of growth, which can be constructed early in infancy.
目前，用于Fontan手术的侧隧道概念已被广泛接受。大多数侧隧道是在主动脉交叉钳夹的情况下在心房内构建的。使用同种异体移植物或其他无活力的管道构建心外膜侧隧道可避免主动脉交叉钳夹，但在长度或宽度上缺乏生长潜力。天然心包沿肺动脉、心房和下腔静脉在后方“密封”，可向下翻转至右心房以形成有活力的心外膜侧隧道。
我们设计并成功地为19例年龄在9个月至5岁的患者使用有活力的自体心包构建了心外膜侧隧道，该心包以其外侧血液供应为蒂。所有患者此前均接受过Glenn分流术；5例患者有右位心和下腔静脉中线走行。横向切开患者的下腔静脉 - 右心房连接部，将右心房开口缝合至其后壁，同时保留下腔静脉内的欧氏瓣。纵向切开右肺动脉的下侧；将其下缘缝合至相邻的心包返折处。沿着肺静脉的心包后壁的任何“袋状”或凹陷处用连续缝合关闭。在右心包内平行于下腔静脉和肺动脉开口向下至膈神经处做两个切口。将这个带蒂心包修剪后作为顶缝合至下腔静脉和肺动脉开口的上缘，然后沿着未切开的右心房壁纵向缝合，完成有活力的心外膜侧隧道的构建。虽然未使用开窗，但在构建过程中可以开窗，或者更重要的是，由于缺乏厚壁结构，在术后可在导管室开窗。
由于侧隧道具有可压缩性，所有19例患者的肺动脉均有呼吸/心脏搏动。随访长达2年半，所有隧道均在生长且未出现梗阻。
有活力的自体心包心外膜侧隧道可以在无心脏缺血的情况下构建，术后可开窗，形成一个可压缩、不形成血栓且能够生长的管道，可在婴儿早期构建。
