Journal of Chest Surgery

  • 제37권8호
  • /
  • Pages.644-651
  • /
  • 2004
  • /
  • 2765-1606(pISSN)
  • /
  • 2765-1614(eISSN)
대한심장혈관흉부외과학회 (The Korean Society for Thoracic and Cardiovascular Surgery)
권호 표지

폰탄 수술에서의 부정맥수술

Arrhythmia Surgery in Fontan Operation

  • 임홍국 (서울대학교병원 흉부외과, 서울대학교 의과대학 흉부외과학교실) ;
  • 한국남 (서울대학교병원 흉부외과, 서울대학교 의과대학 흉부외과학교) ;
  • 김웅한 (서울대학교병원 흉부외과, 서울대학교 의과대학 흉부외과학교) ;
  • 이정렬 (서울대학교병원 흉부외과, 서울대학교 의과대학 흉부외과학교) ;
  • 노준량 (서울대학교병원 흉부외과, 서울대학교 의과대학 흉부외과학교) ;
  • 김용진 (서울대학교병원 흉부외과, 서울대학교 의과대학 흉부외과학교실)
  • 발행 : 2004.08.01
PDF 다운로드
⟨ 이전 논문 다음 논문 ⟩

초록

배경: 폰탄 술식 후 추적과정 동안 혈역학적 이상에 부정맥이 발생하는 경우 예후 및 사망률에 심각한 영향을 미칠 수 있다. 본 연구에서는 폰탄 술식 후 발생한 부정맥의 종류 및 빈도에 대하여 평가하고, 폰탄 술식과 관련하여 부정맥수술을 시행한 환자들에 대한 후향적 임상분석을 시행하였다. 대상 및 방법: 1986년 6월부터 2004년 3월까지 폰탄 수술을 받고 조기 생존한 275명의 환자를 대상으로 하였고, 폰탄 수술과 관련하여 부정맥수술을 한 환자는 46명이었다. 폰탄 수술 후 재수술 시 시행한 부정맥수술이 14예였으며, 재수술 당시 평균 연령은 16.8$\pm$7.1 (범위 4.5∼30.6)세였다. 부정맥은 심방 조동이 8예였으며, 심방세동이 2예였다. 부정맥수술은 냉동소작술에 의한 협부차단이 12예였고, 우측maze 술식이 2예였다. 첫 폰탄 수술 시 동반 술식으로 예방적 냉동소작술에 의한 협부 차단을 32예에서 시행하였다. 결과: 폰탄 술식 후 추적관찰 동안에 부정맥의 발생은 조기 생존한 275명 중 68명(24.7%)에서 발생하였다. 폰탄 수술과 관련하여 시행한 부정맥 수술 후 조기 및 만기 사망은 없었다. 폰탄 수술 후 재수술 시 시행한 부정맥수술 후 평균 26.5$\pm$29.1 (범위: 2∼73)개월 동안의 추적 관찰 기간 중 14명의 환자에서 정상동율동을 보이고 있다. 3예에서 일시적 심방 조동이 재발하여 항부정맥 약물 투여 후 정상 동율동을 보였으며, 7명은 영구형 심박조율기가 필요하였다. 환자의 증상은 수술 전 NYHA 기능분류 IV (2예), III (8예), II (4예)에서 수술 후 I (11예), II (3예)로 호전되었다. 첫 폰탄 수술 시 동반 술식으로 예방적 냉동소작슬을 시행한 환자에서는 평균 51.3$\pm$19.8 (범위: 4∼80)개월 동안의 추적 관찰 기간 중 28명(90.3%)의 환자에서 정상동율동을 보이고 있으며, 심실성기외수축과 접합부성 빈맥이 1예, 동기능장애가 1예, 방실전도차단이 1예로 3명에서 부정맥이 발생하였다. 결론: 폰탄 환자에 대한 적절한 부정맥수술로 동율동 유지를 통한 증상의 완화 및 기능적 분류의 호전을 볼 수 있어 임상 경과와 예후에 도움이 되었다.

Background: Refractory atrial arrhythmias in patients late after the Fontan operation result in significant morbidity and mortality. We reviewed our experience with arrhythmia surgery in patients who had Fontan operation. Material and Method: Between July 1986 and December 2003, 275 early survivors after Fontan operation were reviewed. Fourteen patients underwent. arrhythmia surgery at reoperation after Fontan operation, and mean age at reoperation was 16.8$\pm$7.1 (range: 4.5 ∼ 30.6) years. Mechanisms of arrhythmia included atrial flutter in 8 patients, and atrial fibrillation in 2. Arrhythmia surgery has evolved from isthmus cryoablation in 12 patients to right-sided maze in 2 patients. Thirty-two patients. underwent prophylactic isthmus cryoablation concomitantly at initial Fontan operation. Result: Postoperative arrhythmias occurred in 68 patients (24.7%) among 275. There was no early and late mortality after the arrhythmia surgery. After redo Fontan operation, all patients maintained normal sinus rhythm. Atrial flutter recurred in 3 patients who had sinus conversion with medication and 7 required permanent pacemakers with a mean follow-up of 26.5$\pm$29.1 (range: 2 ∼ 73) months. All patients have improved to NYHA class I or II. After prophylactic cryoablation at initial Fontan operation, 29 patients (90.6%) had sinus rhythm, 1 patient had junctional tachycardia, 1 patient had sinus nodal dysfunction, and 1 patient had AV block with a mean follow-up of 51.3$\pm$19.8 (range: 4∼80) months. Conclusion: Redo Fontan operation, and concomitant arrhythmia surgery reduced atrial arrhythmias and improved NYHA functional classification.

키워드

참고문헌

  1. J Am Coll Cardiol v.37 The Fontan procedure for tricuspid atresia:early and late results of a 25-year experience with 216 patients Mair DD;Puga FJ;Danielson GK https://doi.org/10.1016/S0735-1097(00)01164-5
  2. J Thorac Cardiovasc Surg v.122 Total cavopulmonary conversion and maze procedure for patients with failure of the Fontan operation Mavroudis C;Backer CL;Deal BJ;Hohnsrude C;Strasburger J https://doi.org/10.1067/mtc.2001.117840
  3. J Thorac Cardiovasc Surg v.113 Factors that influence the development of atrial flutter after the Fontan operation Fishberger SB;Wernovsky G;Gentles TL(et al.) https://doi.org/10.1016/S0022-5223(97)70402-1
  4. J Am Coll Cardiol v.39 Influence of patient factors and ablative technologies on outcomes of radiofrequency ablation of intra-atrial re-entrant tachycardia in patients with congenital heart disease Triedman JK;Alexander ME;Love B A (et al.) https://doi.org/10.1016/S0735-1097(02)01858-2
  5. Ann Thorac Surg v.58 Conversion of atriopulmonary to cavopulmonary anastomosis in management of late arrhythmias and atrial thrombosis Kao JM;Alejos JC;Grant PW;Williams RG;Shannon KM;Laks H https://doi.org/10.1016/0003-4975(94)91945-3
  6. Ann Thorac Surg v.62 Revision of previous Fontan connections to extracardiac or intraatrial conduit cavopulmonary anastomosis McElhinney DB;Reddy VM;Moore P;Hanley FL https://doi.org/10.1016/0003-4975(96)00567-X
  7. J Thorac Cardiovasc Surg v.111 Conversion of modified Fontan procedure to lateral atrial tunnel cavopulmonary anastomosis Kreutzer J;Keane JF;Lock JE(et al.) https://doi.org/10.1016/S0022-5223(96)70218-0
  8. Eur J Cardiothorac Surg v.15 Conversion of atriopulmonary or lateral atrial tunnel cavopulmonary anastomosis to extracardiac conduit Fontan modification Van Son JA;Mohr FW;Hambsch J;Schneider P;Hess H;Hass,G.S. https://doi.org/10.1016/S1010-7940(98)00315-7
  9. Ann Thorac Surg v.61 Clinical improvement after revision in Fontan patients Vitullo DA;DeLeon SY;Berry TE (et al.) https://doi.org/10.1016/0003-4975(96)00192-0
  10. Adv Card Surg v.9 Revision of the traditional atriopulmonary Fontan connection Scholl FG;Alejos JC;Laks H
  11. J Thorac Cardiovasc Surg v.115 Fontan conversion to cavopumonary connection and arrhythmia circuit cryoablation Mavroudis C;Backer CL;Deal BJ;Johnsrude C https://doi.org/10.1016/S0022-5223(98)70316-2
  12. Am J Cardiol v.83 Impact of arrhythmia circuit cryoablation during Fontan conversion for refractory atrial tachycardia Deal BJ;Mavroudis C;Backer CL;Johnsrude CL;Rocchini AP https://doi.org/10.1016/S0002-9149(98)00914-X
  13. Circulation v.106 Comparison of anatomic isthmus block with the modified right atrial maze procedure for late atrial tachycardia in Fontan patients Deal BJ;Mavroudis C;Backer CL;Buck SH;Johnsrude C https://doi.org/10.1161/01.CIR.0000025876.82336.26
  14. J Thorac Cardiovasc Surg v.111 Atrial flutter after lateral tunnel construction in the modified Fontan operation:A canine model Rodefeld MD;Bromberg BI https://doi.org/10.1016/S0022-5223(96)70303-3
  15. Ann Thorac Surg v.61 Lateral tunnel suture line variation reduces atrial flutter after the modified Fontan operation Gandhi SK;Bromberg BI;Rodefeld MD (et al.) https://doi.org/10.1016/0003-4975(96)00123-3
  16. J Am Coll Cardiol v.30 Spontaneous atrial flutter in a chronic canine model of the modified Fontan operation Gandhi SK;Bromberg BI;Rodefeld MD (et al.) https://doi.org/10.1016/S0735-1097(97)00263-5
  17. J Thorac Cardiovasc Surg v.112 Anatomically based ablation of atrial flutter in an acute canine model of the mocified Fontan operation Rodefeld MD;Gandhi SK;Huddleston CB (et al.) https://doi.org/10.1016/S0022-5223(96)70089-2
  18. J Thorac Cardiovasc Surg v.111 Staged operation to Fontan increases the incidence of sinoatrial node dysfunction Manning PB;Mayer JE;Wernovsky G;Fishberger SB;Walsh EP https://doi.org/10.1016/S0022-5223(96)70344-6
  19. J Am Coll Cardiol v.17 Electrophysiologic findings after Fontan repair of functional single ventricle Kurer CC;Tanner CS;Vetter VL
  20. Circulation v.93 Ablation of incisional reentrant tachycardia complicating surgery for congenital heart disease:use of entainment to define a critical isthmus of conduction Kalman JM;VanHare GF;Olgin JE;Saxon LA;Stark SI;Lesh MD https://doi.org/10.1161/01.CIR.93.3.502
  21. Pro Pediatr Cardiol v.16 Arrhythmia management of patients with Fontan physiology Triedman JK https://doi.org/10.1016/S1058-9813(02)00045-0
  22. Circulation v.92 no.SUP.Ⅱ Loss of sinus rhythm after total cavopulmonary connection KaveyREW;Gaum WE;Byrum CJ;Smith FC;Kveselis DA https://doi.org/10.1161/01.CIR.92.9.304
  23. J Thorac Cardiovasc Surg v.120 Modifications to the cavopulmonary anastomosis do not eliminate early sinus node dysfunction Cohen MI;Bridges ND;Gaynor JW (et al.) https://doi.org/10.1067/mtc.2000.109708
  24. Int J Cardiol v.88 Sinus node dysfunction after Fontan modifications-influence of surgical method Bae EJ;Lee JY;Noh CI;Kim WH;Kim YJ https://doi.org/10.1016/S0167-5273(02)00530-2
  25. Pacing Clinical Electrophysiol v.20 Permanent overdirve atrial pacing in the chronic management of recurrent postoperative atrial tachycardia in patients with complex congenital heart disease Ragonese P;Drago F;Guccione P;Santilli A;Silvetti MS;Agostino D https://doi.org/10.1111/j.1540-8159.1997.tb05460.x
  26. Ann Thorac Surg v.61 Characterization and surgical ablation of atrial flutter after the classic Fontan repair Gandhi SK;Bromberg BI;Schuessler RB (et al.) https://doi.org/10.1016/0003-4975(96)00186-5
  27. Korean J Thorac Chardiovasc Surg v.36 Surgical treatment of complications after Fontan oeration park JJ;Hong JM;Kim YJ;Lee JR;Rho JR
  28. J Thorac Cardiovasc Surg v.127 Modification to the Fontan procedure for the prophylaxis of intra-atrial reentrant tachycardia:Short-term results of a prospective randomized blinded trial Collins KK;Rhee EK;Delucca JM (et al.) https://doi.org/10.1016/S0022-5223(03)01055-9