Journal of Chest Surgery

The Korean Society for Thoracic and Cardiovascular Surgery (대한심장혈관흉부외과학회)
권호 표지

Results of Extracardiac Pericardial-flap Lateral Tunnel Fontan Operation

자가심낭막절편을 이용한 심외외측통로 Fontan 수술의 결과

  • Park Han-Ki (Department of Thoracic and Cardiovascular Surgery, College of Medicine, Yonsei University) ;
  • Youn Young-Nam (Department of Thoracic and Cardiovascular Surgery, College of Medicine, Yonsei University) ;
  • Yang Hong-Seok (Department of Thoracic and Cardiovascular Surgery, College of Medicine, Yonsei University) ;
  • Yoo Byoung-Won (Department of Pediatrics, Yonsei University College of Medicine) ;
  • Choi Jae-Young (Department of Pediatrics, Yonsei University College of Medicine) ;
  • Park Young-Hwan (Department of Thoracic and Cardiovascular Surgery, College of Medicine, Yonsei University)
  • 박한기 (연세대학교 의과대학 흉부외과학교실) ;
  • 윤영남 (연세대학교 의과대학 흉부외과학교실) ;
  • 양홍석 (연세대학교 의과대학 흉부외과학교실) ;
  • 유병원 (연세대학교 의과대학 소아과학교실) ;
  • 최재영 (연세대학교 의과대학 소아과학교실) ;
  • 박영환 (연세대학교 의과대학 흉부외과학교실)
  • Published : 2006.04.01
Download PDF
⟨ Previous Next ⟩

Abstract

Background: Extracardiac pericardial-flap lateral tunnel Fontan operation has theoretical advantage of growth potentiality of the extracardiac tunnels. The mid-term results of this technique and morphologic change of the lateral tunnel were studied. Material and Method: Clinical data was reviewed in 42 patients who underwent extracardiac pericardial-flap lateral tunnel Fontan operation between November 1993 and December 2004. The age was $2.8{\pm}1.5$ years and the body weight was $12.3{\pm}3.2$ kg. Extracardiac tunnel was constructed using the pedicled pericardium with the base undetached. By reviewing the follow-up cardiac angiograms, the diameter and the cross-sectional area of the lateral tunnel was compared to those of inferior vena cava. Result: There were four operative mortality cases (9.8%) and the causes of death were low cardiac output for all four cases. Postoperatively, five patients had prolonged pleural effusion longer than two weeks and one patient required a permanent pacemaker due to complete heart block. Follow-up was possible in 37 patients and the follow up duration was $3.8{\pm}2.2$ years. During that period, one patient died, of upper gastrointestional bleeding combined with heart failure and one patient died a sudden death of unknown cause. Two patients required reoperation due to subaortic stenosis and anastomosis site stenosis between inferior vena cava and lateral tunnel. In one patient, bradyarrhythmia was anew but there was no thromboembolic complication. The lateral tunnel showed growth in proportion to the size of the inferior vena cava. Conclusion: Extracardiac pericardial-flap lateral tunnel Fontan operation is relatively simple and safe. The mid-term result was favorable and the extracardiac tunnel showed potential for growth.

목적: 자가심낭막을 절편으로 이용한 심외외측통로 Fontan 수술은 심외통로가 성장할 수 있다는 이론적 장점을 가지고 있다. 이 수술기법의 중기성적과 심외통로의 형태학적 변화를 연구하였다. 대상 및 방법: 1993년 11월부터 2004년 12월 사이에 자가심낭막절편을 이용한 심외외측통로 Fontan수술을 시행 받은 42명 환자의 임상자료를 검토하였다. 환자의 나이는 $2.8{\pm}1.5$세였으며, 체중은 $12.3{\pm}3.2$ kg이었다. 체외외측통로는 자가심낭막을 이용하여 기저부를 유지한 상태로 제작하였다. 추적관찰 심조영술을 검토하여 하대정맥에 대한 심외통로의 직경과 단면적을 비교해 보았다. 결과: 수술사망은 4명(9.8%)이었으며, 4예 모두 저심박출증으로 사망하였다. 5명의 환자에서 2주 이상 흉막삼출이 지속되었으며, 1명의 환자가 완전방실차단으로 영구심박동기를 삽입을 요하였다. 37명에서 추적관찰이 가능하였으며 추적관찰기간은 $3.8{\pm}2.2$년이었다. 2명의 환자가 추적관찰기간 중 사망하였는데, 사망의 원인은 각각 상부장관출혈과 원인을 알 수 없는 급사였다. 2명의 환자에서 각각 대동맥판막하 협착과,심외통로와 하대정맥의 연결부위 협착으로 재수술을 받았다. 추적 기간 중 새로 발생한 부정맥은 1명에게서 발견되었고, 혈전 및 색전증에 의한 합병증은 발생하지 않았다. 결론: 자가심낭막을 이용한 심외외측통로 도관 Fontan수술법은 술식이 비교적 간단하고 안전한 방법이다. 수술 후 중기 성적은 양호하며, 심외통로는 성장할 수 있었다.

Keywords

References

  1. De Leval MR, Kilner P, Gewillig M, Bull C. Total cavopulmonary connection: a logical alternative to atriopulmonary connection for complex Fontan operations. Experimental studies and early clinical experience. J Thorac Cardiovasc Surg 1988;96:682-95
  2. Lee JY, Kim YJ, Rho JR. Mid-term results of intracardiac lateral tunnel Fontan procedure in the treatment of patients with a functional single ventricle. Korean J Thorac Cardiovasc Surg 1998;31:472-80
  3. Stamm C, Friehs I, Mayer JE, et al. Long-term results of the lateral tunnel Fontan operation. J Thorac Cardiovasc Surg 2001;121:28-41 https://doi.org/10.1067/mtc.2001.111422
  4. Puga FJ, Chiavarelli M, Hagler DJ. Modifications of the Fontan operation applicable to patients with left atrioventricular valve atresia or single atrioventricular valve. Circulation 1988;76:53-60
  5. Pearl JM, Laks H, Stein DG, Drinkwater DC, George BL, Williams RG. Total cavopulmonary anastomosis versus conventional modified Fontan procedure. Ann Thorac Surg 1991;52:189-96 https://doi.org/10.1016/0003-4975(91)91335-S
  6. Hvass U, Pansard Y, Bohm G, Depoix JP, Enguerrand D, Worms AM. Bicaval pulmonary connection in tricuspid atresia using an extracardiac tube of autologous pediculated pericardium to bridge inferior vena cava. Eur J Cardiothorac Surg 1992;6:49-51 https://doi.org/10.1016/1010-7940(92)90099-J
  7. Gundry SR, Razzouk AJ, del Rio MJ, Shirali G, Bailey LL. The optimal Fontan connection a growing extracardiac lateral tunnel with pedicled pericardium. J Thorac Cardiovasc Surg 1997;114:552-8 https://doi.org/10.1016/S0022-5223(97)70043-6
  8. Kim WH, Chung DH, Kim SC, et al. Early results of extracardiac Fontan operation. Korean J Thorac Cardiovasc Surg 1998;31:650-9
  9. Humes RA, Feldt RH, Porter CJ, Julsrud PR, Puga FJ, Danielson GK. The modified Fontan operation for asplenia and polysplenia syndromes. J Thorac Cardiovasc Surg 1988; 96:212-8
  10. Nawa S, Teramoto S. New extension of the Fontan principle: inferior vena cava-pulmonary artery bridge operation. Thorax 1988;43:1022-3 https://doi.org/10.1136/thx.43.12.1022
  11. Sung SC, Kim S. Early and midterm results of the extracardiac Fontan operation and the change of internal diameter of the conduit. Korean J Thorac Cardiovasc Surg 2002; 35:177-81
  12. Lardo AC, Webber SA, Friehs I, Del Nido PJ, Cape EG. Fluid dynamic comparison of intra-atrial and extracardiac total cavopulmonary connections. J Thorac Cardiovasc Surg 1999;117:697-704 https://doi.org/10.1016/S0022-5223(99)70289-8
  13. Ettinger E, Steinberg I. Angiographic measurement of the cardiac segment of the inferior vena cava in health and cardiovascular disease. Circulation 1962;26:508-15 https://doi.org/10.1161/01.CIR.26.4.508
  14. Prince MR, Novelline RA, Athanasoulis CA, Simon M. The diameter of the inferior vena cava and its implications for the use of vena caval filters. Radiology 1983;149:687-9 https://doi.org/10.1148/radiology.149.3.6647844
  15. 황여주, 이창하, 이재웅 등. 한국인 정상 성인의 하대정맥 크기 측정을 통한 심외도관 폰탄수술에서의 도관 크기의 적정성에 관한 연구. 2005 대한흉부외과학회 제37차 추계학술대회
  16. Alexi-Meskishivili V, Ovroutski S, Ewert P, et al. Optimal conduit size for extracardiac Fontan operation. Eur J Cardio-thorac Surg 2000;18:690-5 https://doi.org/10.1016/S1010-7940(00)00593-5
  17. Uemura H, Yagihara T, Kawahira Y, Yoshikawa Y, Kitamura S. Total cavopulmonary connection in children with body weight less than 10 kg. Eur J Cardio-thorac Surg 2000; 17:543-9 https://doi.org/10.1016/S1010-7940(00)00410-3
  18. Chowdhury UK, Airan B, Kothari SS, et al. Specific issues after extracardiac Fontan operation: ventricular function, growth potential, arrhythmia, and thromboembolism. Ann Thorac Surg 2005;80:665-72 https://doi.org/10.1016/j.athoracsur.2005.02.024
  19. Amin Z, McElhinney DB, Strawn JK, et al. Hemidiaphragmatic paralysis increases postoperative morbidity after a modified Fontan operation. J Thorac Cardiovasc Surg 2001;122:856-62 https://doi.org/10.1067/mtc.2001.118506
  20. Kavarana MN, Pagni S, Recto MR, et al. Seven-year clinical experience with the extracardiac pedicled pericardial Fontan operation. Ann Thorac Surg 2005;80:37-43 https://doi.org/10.1016/j.athoracsur.2005.01.038
  21. Fishberger SB, Wernovski G, Gentles TL, et al. Foactors that influence the development of atrial flutter after the Fontan operation. J Thorac Cardiovasc Surg 1997;113:80-6 https://doi.org/10.1016/S0022-5223(97)70402-1