Relationship between postoperative atrial volumes and prognosis after modified Fontan operation in patients with complex cardiac anomalies

We evaluated right and left atrial (RA and LA) volumes after modified Fontan operation in 6 patients, in 1 with mitral atresia and 5 with single ventricle. The age at operation was 10.2 +/- 2.5 (mean +/- SD) years. The interval between operation and study was 4.1 +/- 4.8 months. RA and LA maximum volume indexes (VImax) (ml/m2) were measured by angiography. One patient died 72 days after operation due to low output syndrome. In survived patients (n = 5), postoperative pulmonary arterial wedge pressure was 6 +/- 3 mmHg, right atrial pressure 13 +/- 5 mmHg, and end-diastolic pressure in the systemic ventricle 6 +/- 3 mmHg, and one who died had 18 mmHg, 25 mmHg, and 9 mmHg in each parameter, respectively. LAVImax in the survivors (53 +/- 18 ml/m2) were in the range of normal or above normal value. The nonsurvivor had extremely small LAVImax (13 ml/m2). RAVImax in the alive patients (25 +/- 11 ml/m2) was smaller than normal (data was not available in a non-survived patient). These results may indicate that a normal LA volume appears to be as important factor for the prognosis after modified Fontan operations with intraatrial routing for complex lesions regardless of the postoperative RA volume.     

Fontan type operation for complex lesions. Surgical considerations to improve survival

Twenty-five of 49 patients who underwent a Fontan type operation had complex lesions other than tricuspid atresia with ventriculoarterial concordance. Three patients had significant subaortic stenosis. Thirty-four palliative operations, including nine Glenn shunts, were performed before the Fontan operation. Direct atriopulmonary anastomosis was performed in 21 patients. In four, valved conduits were used. Twelve patients had right atrioventricular valve patch closure (three had running and nine had interrupted suture technique). On the basis of the presence of increased or decreased pulmonary blood flow before any surgical intervention, patients were divided into Group 1 (previous pulmonary artery banding, N = 8) and Group II (pulmonic stenosis, N = 17). Postoperatively, in Group I, 87% had significant effusions, mean right atrial pressure was higher (20.6 +/- 6.5 torr), and hospital stay longer (31 days). In Group II, 40% had significant effusions, mean right atrial pressure was lower (16.5 +/- 4.3 torr), and hospital stay shorter (15 days). Significant atrioventricular valve patch disruption occurred in three patients (two had running suture technique), and conduit occlusion occurred in two. Four patients (three with subaortic stenosis and pulmonary artery banding) without an established Glenn shunt required Fontan takedown for persistent low cardiac output, two of whom died (2/25 or 8%). There were three late deaths (3/23 or 13%). Nineteen of 20 surviving patients observed from 2 months to 6 years are doing well. We believe that early Fontan takedown in patients with persistent low cardiac output, interrupted suture technique for atrioventricular valve closure, avoidance of valved conduits, and a preliminary Glenn shunt in patients with pulmonary artery banding and/or subaortic stenosis can further improve the results with the Fontan operation for complex lesions.     

改良Fontan手术的危险因素分析

目的 探讨改良Fontan手术后早期死亡的危险因素和手术适应证。方法 统计分析154例改良Fontan手术病人的17个围手术期指标与手术结果。结果 术后早期死亡37例，死亡率24.0%。单因素分析结果表明，术前McGoon比值≤1.8，术前房室瓣存在反流，手术方式，术后右房压≥20mmHg,心律失常，严重低心输出量综合征是手术早期死亡的高危因素，多因素Logistic逐步回归分析结果显示，手术方式（右房与右室连接，右房与肺动脉连接），术后右房压和术后严重低心输出血量综合征与术后早期死亡有关。结论 术前严格选择心室功能和肺动脉发育好，无明显房室瓣反流的病例，采用全腔静脉与肺动脉连接术式，术后加强监护是预防和降低术后早期死亡的有效措施。     

影响肝移植术后早期预后的相关危险因素分析

目的探讨影响肝移植术后早期预后的相关的危险因素。方法回顾性的分析了我院自2003年1月1日至2003年10月31日的原位肝移植病例171例。根据术后早期预后分为预后不良组及非预后不良组（术后早期住院期间死亡者或因各种并发症术后〉7d转出ICU者定为预后不良的病人），比较两组病人术前及术中的变量13项；并筛选出影响预后的一些变量。结果171例病人中，预后不良者30人（17．5％），其中围手术期死亡12人（7％）；应用单因素分析比较预后不良及非预后不良病人的各项指标，以下参数均具有显著性差异：Child分级、APACHEⅢ评分、UNOS分级、手术时间、出血量、输血及血浆量、术前cr水平、术前ICU、术前感染及再次手术干预。将预后作为因变量进行Logistic回归分析，筛选影响预后的危险因素，保留在回归方程中的变量有：APACHEⅢ评分、术前感染、手术时间、术中出血和输血量。而病人年龄、CHILD分级、UNOS分级、无肝期、术前Cr、术前ICU停留、再次手术干预被剔除方程。结论通过对肝移植病人术前及术中一些指标的评估，可以在一定程度上预测术后早期的预后。     

Acute pancreatitis after liver transplantation: incidence and contributing factors

In order to assess the incidence and possible predisposing and contributing factors in the development of acute pancreatitis after liver transplantation, we reviewed the medical records of all 1832 adult patients who underwent 2161 orthotopic liver transplantation (OLTx) procedures in our center between January 1987 and September 1992. Of these patients, 55 (3% incidence) developed clinical pancreatitis and 247 (13.4% incidence) developed hyperamylasemia (biochemical pancreatitis). Overall mortality in cases of clinical pancreatitis was 63.6%. The mortality in cases of hyperamylasemia was similar to that found in the general liver transplant population (i.e., 23%). A strong correlation was found between pancreatitis after liver transplantation and end-stage liver disease due to hepatitis B (30% of the cases, P=0.00001). Extensive surgical dissection around the pancreas (P<0.05), the type of biliary reconstruction following liver transplantation (P<0.05), and the number of liver grafts received by the same patient (P=0.00001) appeared to be possible contributing factors as did the duration of venovenous bypass and the quantity of IV calcium chloride administered intraoperatively.     

Liver fibrosis (cardiac cirrhosis) five years after modified Fontan operation for tricuspid atresia

A 15-year-old girl was found to have severe liver fibrosis on liver biopsy at the time of cholecystectomy, 5 1/2 years following a modified Fontan procedure (right atrial-right ventricular conduit) for tricuspid atresia. Postoperative right atrial pressures were consistently elevated above 13 mm Hg and this, in part, may have been due to progressive mild conduit stenosis. Because of increasing symptoms, the patient underwent successful revision of the conduit at the age of 15 years. It is suggested that sustained systemic venous hypertension caused the striking morphologic changes in the liver and that this serious complication may significantly affect the long-term prognosis of patients surviving the Fontan procedure.     

Early and medium-term results after modified Fontan operation in adults.

OBJECTIVE: Single ventricle palliation is rarely performed in adults and the results are less optimal than in children. In this article we analyze our experience with the modified Fontan operation in this age group. METHODS: Data of 15 consecutive patients with single ventricle with a mean age of 26 (range 16-38) years, who underwent Fontan operation between 3/92 and 1/2000 were retrospectively analyzed. Five patients had previously had an aortopulmonary shunt in childhood and two patients had previously received a bi-directional cavopulmonary shunt as adults. Eleven patients were preoperatively in NYHA class III and four in class II. The main factors for the selection of the patients before surgery were well-developed pulmonary arteries with lower lobe index 120+30 mm/m(2), pulmonary artery pressure <18 mmHg, good cardiac function and enddiastolic systemic ventricular pressure <12 mmHg. The lateral tunnel Fontan operation (LTFO) was performed in ten patients and extracardiac Fontan operation (ECFO) in five. A fenestration 4-5 mm in size was constructed in all patients with LTFO and in three of five patients with ECFO. RESULTS: There was one intraoperative and one late death (total mortality 13%). The mean extubation time and hospital stay were 24 h and 21 days, respectively. Severe postoperative complications were observed in three patients (20%). Two LTFO patients out of a total of eight patients (53%) with perioperative arrhythmias received a permanent pacemaker due to bradyarrhythmia. During the median follow-up of 5.0 (range 2.3-10.1) years, four patients developed arrhythmias; one of them had new onset bradyarrhythmia after LTFO and required permanent pacemaker implantation. The median postoperative oxygen saturation was 93% (range 90-98%). NYHA class improved significantly in 12 survivors. Cardiac catheterization (0.5-4 years postoperatively, n=12) showed excellent Fontan hemodynamics in all patients. CONCLUSIONS: The modified Fontan operation can be performed in adults with acceptable early and midterm mortality and morbidity and leads to either complete or marked relief of cyanosis and enhanced exercise tolerance in all survivors. Postoperative arrhythmias are one of the main drawbacks but the incidence of arrhythmias after ECFO seems to be lower. The long-term follow-up has yet to be established.     

早期移植肾功能异常的相关因素及其预后

目的 探讨早期移植肾功能异常的相关因素及其对移植肾长期存活的影响。方法 根据术后６个月内有无发生急性排斥反应和６个月时的血肌酐水平（ＳＣｒ６月）,将２５１例肾移植患者分为４组：Ａ、Ｂ组未发生急性排斥反应,前者ＳＣｒ６月〈１３０μｍｏｌ／Ｌ,后者ＳＣｒ６月≥１３０μｍｏｌ／Ｌ;Ｃ、Ｄ组为４组：Ａ、Ｂ且未发生急性排斥反应,前者ＳＣｒ６月〈１３０μｍｏｌ／Ｌ,后者ＳＣｒ≥１３０μｍｏｌ／Ｌ。术后各组的免     

原位肝移植术后早期肝功能不全的相关危险因素分析

目的分析原位肝移植术后早期肝功能不全(early allograft dysfunction,EAD)的发生情况,并探讨EAD发生的相关危险因素。方法回顾性分析武汉大学人民医院2016年1月至2020年12月实施的74例原位肝移植病人的临床资料,对可能导致术后EAD的围手术期相关因素进行单因素分析,然后将有显著性差异的因素纳入Logistic回归多因素分析。结果74例肝移植病人术后EAD的发生率为36.5%(27/74)。单因素分析结果显示,受者术前中性粒细胞与淋巴细胞比值(NLR)、术前血清总胆红素、术中失血量、术前肝功能Child-Pugh分级C级、术前终末期肝病模型(MELD)评分≥18分及术后出现胆道及血管并发症是EAD发生的潜在危险因素(均P<0.05);多因素Logistic回归分析结果显示,肝移植术后EAD的独立危险因素为:术前MELD评分≥18分[OR=0.045,95%CI(0.003,0.605),P=0.045];移植术后出现胆道及血管并发症[OR=0.061,95%CI(0.009.0.419),P=0.004]。结论术前MELD评分≥18分及术后出现胆道及血管并发症是影响肝移植术后EAD的独立危险因素。临床上应该通过改善受者术前较差的肝功能和提高临床医师手术技巧来降低EAD的发生率。     

Predictive factors and long-term evolution of early endothelial dysfunction after cardiac transplantation.

BACKGROUND: Abnormal coronary vasomotion appears to be a common finding after heart transplantation (HTx). However, the pathophysiology and outcome of this functional disturbance remains poorly understood. Aims of the study were to determine the prevalence, predictive factors and long-term evolution of endothelial dysfunction after cardiac transplantation. METHODS: The endothelium-dependent coronary vasomotion of 50 patients, who showed angiographically normal coronary arteries, were studied early (at 3 +/- 1 months) and at follow-up (16 +/- 5 months) after HTx. Endothelial function was studied by selective infusion of serial doses of acetylcholine (ACh) (10(-8), 10(-7)and 10(-6) mol/l) in the left anterior descending coronary artery. Changes in mean luminal diameter after the infusion of each dose were evaluated by quantitative coronary angiography (QCA). RESULTS: At early study, 17 patients (34%) showed a vasoconstriction after maximal dose of ACh (-13.3 +/- 13%) indicative of endothelial dysfunction. Logistic regression analysis identified the following variables as independent predictors of early endothelial dysfunction: donor inotropic support (p = 0.004), female donor (p = 0.04) and rejection at the time of the study (p = 0.01). Forty-one patients were re-studied at follow-up. Nine of them (22%) presented endothelial dysfunction. Early endothelial dysfunction was restored in 6 patients (43%) at follow-up. The number of episodes of rejection was the only variable associated to late endothelial dysfunction. CONCLUSIONS: Endothelial dysfunction is a common finding after cardiac transplantation. The pathogenesis of this functional disturbance appears to be donor-related and immune-mediated. The reversibility of this phenomenon observed at follow-up suggests the episodic nature of the immunologic injury.     

A reconsideration of risk factors for the Fontan operation.

We reviewed our experience in 38 patients who underwent a Fontan operation. In the first five patients ages 7.5 to 23 years (mean, 15 years), a conduit was placed from the right atrium to the small right ventricle or the pulmonary artery (PA). The remaining 33 patients, ages 7 months to 14 years (mean, 4.8 years), had a modified Fontan operation with direct systemic venous or right atrial to PA anastomosis. The diagnoses were tricuspid atresia (n = 14), single ventricle (n = 10), hypoplastic right or left ventricle (n = 9), double-outlet right ventricle with inlet ventricular septal defect and pulmonary atresia or stenosis (n = 3), criss-cross ventricles and transposition of the great arteries (n = 1), and atrioventricular canal and anomalous pulmonary venous connection (n = 1). Thirty-two patients had previous surgery. Other procedures included PA banding (n = 7), systemic to PA shunts (n = 25), Norwood operation (n = 3), and a Damus-Kaye-Stansel anastomosis (n = 1), repair of total anomolous pulmonary venous connection (n = 1), a Blalock-Hanlon atrial septectomy (n = 1), and enlargement of a restrictive ventricular septal defect (n = 1). There were four operative deaths (10.5%), three from low cardiac output and one from subaortic obstruction. There were no deaths in patients younger than 3 years of age (n = 13). Subaortic obstruction developed in six of the seven patients who had pulmonary artery banding and resulted in three deaths. In our experience, diagnosis, previous surgery, type of previous operation, PA pressure, and younger age are not risk factors for early or late death. Subaortic obstruction is a major risk factor for late death. Accordingly we now perform a Damus-Kaye-Stansel anastomosis combined with a systemic to PA shunt in those children with excessive pulmonary blood flow who anatomically are likely to develop subaortic obstruction. A modified Fontan operation can be performed any time after 1 year of age and in some patients after 6 months of age, providing the anatomy and physiology of the patient are acceptable.     

Therapeutic use of right atrial pressures early after the Fontan operation

In 334 patients undergoing the Fontan operation, the right atrial pressure was 16 +/- 36 mm Hg (mean value +/- SD) 3 h postoperatively, and was on average higher in those who died or had a takedown of the operation than in those who did not (P = 0.0001). Twenty-four hours after operation, the right atrial pressure was 18 +/- 5.5 mm Hg, was higher in those who died or had a takedown than in those who did not (P less than 0.0001); and in those who died or had takedown it was 23.5 +/- 1.66 mm Hg and higher than at 3 h postoperatively (18.7 +/- 0.52). The left atrial pressure 3 h postoperatively was 9 +/- 3.6 mm Hg, and on average was higher in the patients who died or had a Fontan takedown than in those who did not. The continuous relation between right atrial pressure and the probability of death or takedown during the first 24 postoperative hours was such as to recommend consideration of takedown whenever the right atrial pressure reaches 22 mm Hg, and when higher, the recommendation is made with greater urgency.     

公民逝世后器官捐献原位肝移植后早期肝功能不全的危险因素分析

目的 观察公民逝世后器官捐献原位肝移植术后早期肝功能不全（early allograft dysfunction,EAD）的发生情况,探讨早期肝功能不全的危险因素。方法 回顾性分析2017年1月至2019年12月间我院65例行肝移植供、受体资料。根据术后情况将患者分为EAD组（n=29）及非EAD组（n=35）。对相关因素先进行单因素分析,然后将统计学差异的因素进行多因素Logistic回归模型分析。结果 65例原位肝移植患者术后早期肝功能不全的患者有29例,发生率为44.6%。单因素分析显示EAD组与非EAD组供体血清钠[（157.53±21.71）mmol/L vs（146.06±15.24）mmol/L,P=0.019]、热缺血时间[（21.6±6.5）min vs（10.6±4.3）min,P=0.016]、冷缺血时间[（8.3±1.2）h vs（5.4±1.2）h,P=0.012]、ICU住院时间[（78.1±19.5）h vs（49.7±17.6）h,P=0.007]及受体的无肝期时间[（98.3±16.3）h vs（66.0±17.6）h,P=0.037]差异均有统计学意义。多因素Logistic回归分析结果显示影响术后早期肝功能不全的独立危险因素为供体血清钠水平（OR 18.372,95%CI 1.846～24.173,P=0.019）及热缺血时间（OR 8.105,95%CI 1.513～37.205,P=0.013）。结论 供体血清钠水平及热缺血时间是公民逝世后器官原位肝移植术后EAD的独立危险因素。     

Clinical and subclinical acute rejection early after liver transplantation: contributing factors and relevance for the long-term course

Routine transplant aspiration cytology (TAC) after liver transplantation gives detailed information that concerns immunologic events in the graft. TAC can be helpful for diagnosis of acute rejection, but it also detects morphological signs of rejection without clinical correlate ("subclinical rejection"). The aim of this study was to systematically evaluate factors that influence the development of early clinical and subclinical rejection and to analyze the relevance of these early immunologic processes for the long-term course. The study includes the course of 340 patients after liver transplantation between 1988 and 1995 in whom TAC was performed routinely and who were followed for a minimum of 3 years. TAC findings were correlated with the following various clinical parameters: (1) Overall early clinical rejection occurred in 17.4%, subclinical rejection in 59.1%, and no immune activation was seen in 23.5% of patients. (2) Incidence of early clinical and subclinical rejection was markedly influenced by type of immunosuppression. (3) Basic disease and extent of preservation injury had only a minor influence; there was a trend towards lower early rejection associated with more severe preservation damage, increased patient age, and early retransplantation. (4) Presence of early clinical or subclinical rejection was not associated with a higher incidence of chronic dysfunction. (5) Falsely indicated antirejection treatment was associated with inferior graft survival. Subclinical rejection is very frequent early after liver transplantation, requires no treatment, and has no long-term adverse effect. Incidence of early clinical rejection is mainly determined by initial immunosuppression; its occurrence has no negative long-term effects and may even be associated with a lower risk for later immunological complications. Thus, the incidence of early acute rejection is no adequate parameter for evaluating the quality of an immunosuppressive treatment protocol.     

Tricuspid atresia versus other complex lesions. Comparison of results with a modified Fontan procedure

Several modifications of the Fontan principle are currently applied to the treatment of tricuspid atresia with low mortality. The use of these modifications in other malformations has most frequently been associated with less satisfactory results. At our institution, from June 1977 to October 1986, 35 consecutive patients, whose ages ranged from 8 months to 20 years (median age 3.4 years), underwent a modified Fontan procedure. Twenty patients with a median age of 3.2 years (group I) having tricuspid atresia (16 patients) or hypoplastic right heart syndrome (four patients) were treated by means of a right atrium-pulmonary artery anastomosis (12 patients) or right atrium-subpulmonary chamber connection (eight patients). Fifteen patients (group II) with a median age of 3.6 years, having a single left ventricle (10 patients), left atrioventricular valve hypoplasia or atresia (three patients), or double-outlet right ventricle (two patients), underwent right atrium-pulmonary artery anastomosis, together with a repositioning of the atrial septum to the right of the right atrioventricular valve, which thus left intact the inlet to the ventricle(s). The operative mortality rate was 25% in group I and 0% in group II. One patient in group I and one in group II died late postoperatively. All the 28 survivors are free of symptoms 3 months to 9 years after correction. According to our results, low risk can be associated with modified Fontan procedures in the treatment of complex heart malformations other than tricuspid or pulmonary atresia. Preserving the integrity of the entire inlet to the ventricle(s) by repositioning the interatrial septum, as done in group II malformations, might be helpful in improving the quality of the repair.     

Repair of atrioventricular valve regurgitation in the modified Fontan operation.

OBJECTIVE: To evaluate the prevalence, impact and outcome of repair of atrioventricular valve regurgitation (AVVR) in Fontan patients. METHODS: We retrospectively reviewed 340 Fontan patients from 1986 to 2001. Twelve patients with valve closure or replacements were excluded. AVVR was graded by transthoracic echocardiography. Patients were divided into group O (no AVVR), group A (1+ to 2+) and group B (3+ to 4+). RESULTS: AVVR was present in 129 (39.3%) patients. Repair was carried out in 37 (11.3%) with no difference in mortality as compared to no repair (18.9 vs 10.9%, P =0.16). Mean follow-up was 44 months (1-197 months) with 14 patients lost to follow-up. No valve repair was carried out in group O (192 patients) and no clinical change in AVVR was observed (pre-op 0.00, post-op 0.78). In group A (85 patients) 6 patients had valve repair without significant change in the degree of AVVR after valve repair (pre-op 1.8, post-op 2.2, P = 0.18). In group B (44 patients) 31 had valve repair and a significant reduction was observed (pre-op 3.28, post-op 2.44, P < 0.001). A similar improvement was also observed when the valve was not repaired (pre-op 3.25, post-op 2.44, P = 0.003). Survival at 10 years was comparable (83% repaired, 89% not repaired, P = 0.165). There was no difference in the incidence of long-term complications (26% repaired, 29.7% no repair, P = 0.64). CONCLUSIONS: Trivial to mild AVVR remains stable and their repair during the Fontan operation provides no additional benefits. Valve repair in patients with moderate to severe AVVR improved the regurgitation with comparable operative mortality and long-term outcome; however, similar benefits could be achieved without repair of the atrioventricular valve. We should not deny patients with similar AVVR the Fontan operation.     

轻中度及中度房室瓣膜反流在Fontan术后的预后和相关危险因素分析

目的 研究轻中度、中度房室瓣膜反流在Fontan术后的预后及危险因素.方法 将2004～2018年房室瓣膜反流为轻中度、中度于本中心行Fontan术和瓣膜成形手术的34例患者作为成形组,在同期患者中以1∶1～2的比例匹配对照组患者65例.共入组99例,其中男64例、女35例,年龄(63.4±36.3)个月,体重(17....