Fontan conversion with arrhythmia surgery.

OBJECTIVE: Hemodynamic abnormalities and refractory atrial arrhythmias in patients late after the Fontan operation result in significant morbidity and mortality. We reviewed our experience with Fontan conversion and concomitant arrhythmia surgery. METHODS: Between January 1996 and February 2004, 16 patients underwent Fontan conversion and arrhythmia surgery. Mean age at the initial Fontan operation was 5.1+/-3.5 (range: 2-15) years and mean age at Fontan conversion was 17.0+/-5.8 (range: 6-30). The initial Fontan operations were atriopulmonary connections in 14 patients, extracardiac lateral tunnel in 1, and intracardiac lateral tunnel in 1. The types of arrhythmia included atrial flutter in 10 patients and atrial fibrillation in 3. Fontan conversion operation was performed with intracardiac lateral tunnel in 5 patients and extracardiac conduit in 11. Arrhythmia surgery included isthmus cryoablation in 10 patients and right-sided maze in 3. RESULTS: There has been no mortality. At Fontan conversion operation, 7 patients required permanent pacemaker. All patients have improved to New York Heart Association class I or II. With a mean follow-up of 26.9+/-30.6 (range:1-87) months, 16 patients had sinus rhythm, 2 patients had transient atrial flutter which was well controlled, and 2 patients required permanent pacemaker during follow-up. CONCLUSIONS: Fontan conversion with concomitant arrhythmia surgery and permanent pacemaker placement is safe, improves New York Heart Association functional class, and has a low incidence of recurrent arrhythmias. In most patients, concomitant permanent pacemakers are needed.     

The beneficial effects of total cavopulmonary conversion and arrhythmia surgery for the failed Fontan

Postoperative Fontan patients can develop hemodynamic abnormalities and refractory atrial arrhythmias resulting in significant morbidity and mortality. We present our experience with total cavopulmonary artery conversion and arrhythmia surgery. Between 1994 and 2001, 41 patients underwent total cavopulmonary artery conversion and arrhythmia surgery. Significant hemodynamic lesions were repaired concomitantly: aortic aneurysm (n = 1), atrioventricular valve insufficiency (n = 8), and pulmonary artery stenosis (n = 9). Thirty-five patients were in New York Heart Association class III or IV. Mean age at original Fontan was 7.5 ± 6.5 years, at Fontan conversion, 18.7 ± 9.0 years. Arrhythmia surgery for atrial re-entry tachycardia evolved from isthmus cryoablation (n = 10) to right-sided maze (n = 17). Maze-Cox III was used for 14 patients with atrial fibrillation. Atrial (n = 34) and dual chamber (n = 5) pacemakers were placed. Mortality and reoperation for bleeding rates are 0%. Chest tubes were removed on postoperative day 9.0 ± 6.0. Mean hospital stay was 11.8 ± 6.6 days. Three patients required cardiac transplantation at 8 days, 9 months, and 33 months postoperatively. There was one long-term death from acute myocardial infarction 2 years postoperatively. For the entire series, arrhythmia recurrence is 12.2% (5/41). Only 9.8% of patients (4/41) receive chronic antiarrhythmic medications; these patients were among the first eight in the series. Most patients are in New York Heart Association I or II. Bruce protocol in 12 patients showed increased tolerance (P < .05) Total cavopulmonary artery conversion with concomitant arrhythmia surgery is excellent therapy for patients with failed Fontan. It is safe, improves New York Heart Association class, improves exercise tolerance, and the incidence of recurrent arrhythmias is low. Copyright © 2002 by W.B. Saunders Company     

Anaesthetic management of an adolescent for scoliosis surgery with a Fontan circulation

Advances in the treatment of congenital heart disease have led to a new group of adolescents or adults patients with cardiac anomalies. The anaesthetic management of these patients can be challenging especially when they are scheduled for major noncardiac surgery inducing haemodynamic instability. We report the case of a 14-year-old boy scheduled for posterior spinal fusion for idiopathic scoliosis who underwent a Fontan operation in infancy for pulmonary atresia with right ventricle hypoplasia. The preoperative investigations and the anaesthetic management are described.     

External transcutaneous pacemaker for profound bradycardia associated with spinal cord trauma

The successful use of external transthoracic pacing is described in a case of spinal cord trauma with profound bradycardia. This modality achieved blood pressures equal to transvenous pacing. In patients in whom venous access is difficult or represents a risk of infection, transthoracic pacing may offer a worthwhile alternative.     

Extracardiac Fontan conversion, cryoablation, and pacemaker placement for patients with a failed Fontan

OBJECTIVE: We review our experience with Fontan conversion and cryoablation in patients with an atriopulmonary Fontan in low cardiac output from arrhythmia or venous obstruction, including two patients with protein losing enteropathy. METHODS: Fifteen patients (mean age 25.0 +/- 8.4 years) underwent extracardiac Fontan conversion, cryoablation, and pacemaker placement between November 1999 and December 2004. Twelve patients were in NYHA class III and three were in NYHA class IV. Twelve had clinically important intraatrial reentry tachycardia refractory to medical therapy. RESULTS: Follow-up was between 2 and 62 months (mean 38.4 +/- 17.7). One death occurred at seven days after surgery due to sepsis and multisystem organ failure. The second death occurred at five days from myocardial depression following surgery. One patient with PLE preoperatively died to malnutrition and sepsis on POD number 52. The second patient with protein losing enteropathy had improved NYHA classification, cessation of albumin transfusions, and a normal stool alpha antitrypsin level (down from 4.1 mg/g preoperatively). All surviving patients improved NYHA classification to class I or II. Sustained arrhythmias could not be induced in any patient. One patient had recurrence of intraatrial reentrant tachycardia eleven months postoperatively that required electrical cardioversion and is currently well controlled on one medication. The other patients are not on any antiarrhythmic medical therapy. CONCLUSION: Extracardiac Fontan, cryoablation, and pacemaker placement reduced atrial arrhythmias and improved NYHA classification. In selected patients, this operation offers improvement in clinical outcome and is an alternative to transplantation. Protein losing enteropathy may not be a contraindication to performing Fontan conversion with cryoablation.     

介入治疗继发孔房间隔缺损合并心律失常的临床研究

目的介绍介入治疗继发孔房间隔缺损(ASD)合并严重心律失常的临床体会。方法54例心律失常患者中,心房纤颤20例,频发室性早搏10例,频发房性早搏4例,室上性心动过速3例,室性心动过速1例,Ⅰ°房室传导阻滞(AVB)14例,Ⅱ°、Ⅲ°AVB各1例。54例ASD均为中央型,合并肺动脉高压12例,合并其他疾病7例,其中二尖瓣狭窄、二尖瓣脱垂合并关闭不全、脑栓塞、血友病、高血压病、室间隔缺损、动脉导管未闭各1例。54例患者术前、术后常规行TTE检查、胸部X线平片、12导联心电图及右心导管检查。术中均用TTE和TEE监测。结果54例患者均成功地行介入治疗ASD,技术成功率100%。闭合器型号10~40 mm,无任何并发症。5例患者(3例室上性心动过速、1例室性心动过速、1例频发室性早搏)先行射频消融术,而后成功闭合ASD。结论ASD合并心律失常介入治疗,必须特殊对待心律失常,认真掌握各种心律失常治疗原则,而后介入治疗ASD。     

起搏器安置术与冠状动脉造影同时进行的意义及临床安全性探讨

目的：探讨起博器安置术与冠状动脉造影（CAG）同时的临床意义及安全性。方法回顾性分析2012年3月至2013年12月97例植入起搏器患者资料,以是否同时进行CAG分为造影组41例和非造影组56例,观察冠心病在缓慢性心律失常患者中的比例,以及起搏器囊袋出血情况。结果造影组造影检出冠心病25例占59.5%,高于临床诊断的20例（漏诊7例,误诊2例）,占47.6%;造影组发生囊袋出血4例（9.5%）,非造影组发生5例（8.9%）,两组囊袋出血发生率差异无统计学意义（α2=87.46,P＆gt;0.05）。结论起博器安置术与冠状动脉造影同时进行是安全的,且可发现严重的冠脉病变,为下一步治疗提供依据,同时减少住院时间及住院费用,具有一定的临床意义。     

心房内侧隧道Fontan术纠治小儿复杂先天性心脏病47例

目的 总结应用心房内侧隧道Fontan术治疗47例小儿复杂先天性心脏病（先心病）的经验。方法 47例病儿年龄1岁5个月－14岁;体重9－42kg。病种包括三尖闭锁10例,单心室17例,右室双出口14例,完全性大动脉转位2例和纠正性大动脉转位4例。结果 术后早期死亡9例,手术死亡率19.1％。1995年前手术死亡率26.3％（5／19例）,1995年后（含1995年）14.3%(含1995年）14.3%(4/28例）。晚期死亡1例。结论 改良Fontan术适应证已扩大至许多解剖上不能纠治、功能上仅有一个单心室腔的复杂性紫绀型先心病,为提高手术疗效须严格掌握手术适应证;板障上开窗可有效降腔静脉和右房压力,减少胸腔引流量,缩短住院,是高体循环心排出量;少数不能耐受Fontan术后循环生理改变 的难治性低心输出量病儿,应早期果断再手术改建为双向腔肺分流术（半Fontan术）     

肝癌转化治疗相关评估指标及价值

肝癌起病隐匿、发展迅速、恶性程度高,临床上发现时多属中晚期,失去了手术治疗的机会。目前,针对中晚期肝癌的转化治疗使不可切除肝癌变成可切除,已成为肝癌治疗的重要策略与新焦点。转化治疗中涉及对病人肝脏功能评估、血清学肿瘤标记物测定、影像学检查分析、术前肝脏体积计算等,同时须根据实体瘤疗效评估标准对不同状况的病人实施个体化转化治疗策略。因此,了解转化治疗中相关指标及其参考价值是肝胆外科医生必备的知识与技能。     

目标导向性治疗在外科的应用

目标导向性治疗是一种有明确治疗目的的治疗措施,是针对危重病人的,旨在以提高心输出量和组织氧供为目标的一种治疗方法。在外科大型手术和高风险手术中目前已经开始受到重视及应用。并被证实可以降低术后并发症的发生,缩短病人的住院时间。同时,早期应用目标导向性治疗,能够显著降低脓毒症病人的死亡率。本文就目标导向性治疗在外科的应用方面作一综述。     

初始不可切除肝癌转化治疗主要模式及评价

原发性肝癌是我国致死率最高的恶性肿瘤之一,手术切除是其治疗的重要手段,但大部分肝癌病人确诊时已经失去了手术切除的机会.如何将不可手术切除肿瘤转化为可切除成为肝癌临床研究的重要方向.近年来,肝癌的转化治疗发生了翻天覆地的改变,新的治疗方法和药物层出不穷.未来如何精准选择适合转化治疗的肝癌病人、合理选择转化治疗的方案和准确...     

肝癌转化治疗现状与思考

手术切除仍是实现肝细胞癌(HCC)根治和获得长期生存的最重要手段.由于HCC病人初诊为中、晚期比例高达70％～80％,因此,为其争取根治性手术机会对提升HCC总体预后意义重大.源于降期治疗的升级,转化治疗应运而生.系统与局部治疗的多维度联合、多模式序贯显示出了可喜的转化成功率.然而,由于发展时间尚短,诸多问题有待继续深...     

联合治疗在胆道恶性肿瘤转化治疗中的应用探讨

胆道恶性肿瘤起病隐匿、发展迅速,大多患者在发现时已丧失手术机会,预后较差,转化治疗可以达到使患者肿瘤缩小或降期而具备手术条件并完成根治性切除的目的.由于胆道恶性肿瘤极具异质性的特点,其发生发展过程是多因素多途径的结果,因此联合治疗是提升转化治疗成功率、改善预后的主要方向,随着对胆道恶性肿瘤发生发展机制认识的逐渐深入,个...     

初始不可切除肝癌转化治疗后行肝切除术九例临床特征分析

目的 分析初始不可切除的肝癌转化治疗后再行肝切除术的临床特征,为初始不可切除肝癌的治疗提供依据。方法 回顾性分析航天中心医院普外科和北京大学肿瘤医院裕和肿瘤中心2019年1月至2021年4月间收治的9例初始不可切除的肝癌患者临床资料。结果 9例患者均为男性,中位年龄48（33~61）岁;均合并乙肝肝硬化,肝功能Child-Pugh A级4例,B级5例;巴塞罗那分期B期4例,C期5例;PS评分均≤1分。转化治疗方案：6例行帕博利珠单抗联合仑伐替尼治疗,1例行卡瑞利珠单抗联合仑伐替尼治疗,1例行卡瑞利珠单抗联合阿帕替尼治疗,1例行信迪利单抗联合仑伐替尼治疗。治疗过程中发生高血压5例、乏力6例、腹泻2例。转化治疗后再行肝切除术：行左半肝切除术5例,右半肝切除术3例,左半肝联合尾状叶切除术1例,均为R0切除。1例患者因腹腔出血再次手术,其余患者无明显手术相关并发症发生。术后住院时间（12.9±2.1）d;术后中位随访时间10.1个月,随访期间肝癌复发2例,其余7例患者生存状态良好,随访期间无死亡病例出现。结论 免疫治疗联合靶向治疗在初始不可切除的肝癌转化治疗中有效且安全。     

Downstaging and resection of hepatocellular carcinoma in patients with extrahepatic metastases after stereotactic therapy

BackgroundA combination of tyrosine kinase inhibitors (TKIs) and anti-PD-1 antibodies with local regional therapy has elicited yield substantial clinical benefits in patients who have hepatocellular carcinoma (HCC) with extrahepatic metastases. Using this treatment strategy to convert HCC patients with extrahepatic metastases from unresectable to resectable has not yet been reported.MethodsConsecutive hepatocellular carcinoma patients with extrahepatic metastases who received first-line therapy with a combination of TKIs and anti-PD-1 antibodies and at least one local regional therapy were analysed.ResultsNine patients with localized disease who received first-line systemic therapy were enrolled. At baseline, all of them had oligometastatic disease, namely, Barcelona Clinic Liver Cancer stage C (or Chinese Liver Cancer stage IIIB). The most common treatment administered was lenvatinib plus anti-PD-1 antibody and transarterial chemoembolization, and the median time span from systemic therapy to surgery was 3.2 (IQR, 2.8–6.2) months. Three patients achieved a pathological complete response. Six patients underwent laparoscopic surgery, and the other 3 patients underwent open surgery. After a median follow-up of 10.2 (IQR, 8.6–20.0) months, 7 patients survived without disease recurrence, and 2 experienced tumour recurrence. All patients had any-grade AEs, and 55.6% of the patients experienced grade 3 AEs. Fatigue was the most common AE, followed by elevated aminotransferase levels and hypertension.ConclusionsStereotactic therapy is a feasible conversion therapy for HCC patients with extrahepatic metastases to become resectable. This is the first study to analyse therapeutic outcomes of patients receiving these therapies for HCC with extrahepatic metastases.     

免疫联合靶向治疗在晚期肝癌转化治疗中的研究进展

随着肝细胞癌(HCC)发病机制研究的深入,晚期肝癌已经进入到了多种方式、多种药物联合使用的综合治疗时代,尤其是免疫治疗、免疫联合抗血管靶向治疗以及肝动脉灌注化疗等降期转化治疗取得了显著的疗效,给晚期肝癌患者带来了希望。目前免疫联合靶向药物治疗晚期肝癌已经成为了国内外研究的热点之一,阿特利珠单抗联合贝伐珠单抗(T+A)方案更是作为一线治疗方案正式写入了多个指南之中。本文就免疫联合靶向治疗研究进展、适用人群、疗效监测方面进行讨论。     

胃肠外科围手术期的液体治疗

外科液体治疗一直是关注的热点并存在争议。本文就液体治疗对术后肠道功能的影响、液体治疗对外科预后的影响和急性弥漫性腹膜炎围手术期液体治疗三方面进行讨论,应该注意在低灌注状况下胶体的补充和适当的晶／胶体比例。不同液体种类的选择在近年来的研究中未显示出远期效果的显著差异。关注2012SSC严重脓毒症及脓毒性休克指南更新中液体治疗新证据。     

免疫联合靶向治疗在晚期肝癌转化治疗中的研究进展

随着肝细胞癌(HCC)发病机制研究的深入,晚期肝癌已经进入到了多种方式、多种药物联合使用的综合治疗时代,尤其是免疫治疗、免疫联合抗血管靶向治疗以及肝动脉灌注化疗等降期转化治疗取得了显著的疗效,给晚期肝癌患者带来了希望。目前免疫联合靶向药物治疗晚期肝癌已经成为了国内外研究的热点之一,阿特利珠单抗联合贝伐珠单抗(T+A)方案更是作为一线治疗方案正式写入了多个指南之中。本文就免疫联合靶向治疗研究进展、适用人群、疗效监测方面进行讨论。