延长Fontan类手术患者住院时间的危险因素分析

目的分析影响延长Fontan类手术后患者恢复的危险因素。方法回顾性分析2012年1月至2013年6月阜外心血管病医院60例行Fontan类手术患者的基本资料、术前导管及超声资料，术前、术中及术后血流动力学资料和血液指标资料。根据住院时间不同，将60例患者分为两组，正常恢复组[45例，男33例，女12例；年龄（5．7±1．7）岁，住院时间〈32．5d]和延迟恢复组[15例，男10例，女5例；年龄（4．9±1．6）岁，住院时间〉32．5d，延迟恢复组指超出75％分位住院时间者]。60例患者住院时间12～53d，75％分位住院时间为32．5d。比较两组患者的临床资料，分析影响术后恢复的危险因素。结果术前脉搏血氧饱和度80．5％±7．4％，术前射血分数64．1％±6．6％，肺动脉指数（370．6±234．2）mm^2／m^2，McGoon比值2．2±0．7，术前平均肺动脉压（12．4±4．0）mmHg。Fontan类手术前行Glenn手术27例（45．0％），行Glenn手术患者的年龄0．9～4．0岁，距离Fontan类手术1．0～5．1年。患者住院期间死亡2例（3．3％）。55例并行循环下手术体外循环时间（112．0±52．4）min；5例患者需要停循环修补心内畸形，主动脉阻断时间（44．8±9．2）min。呼吸机辅助呼吸时间（18．8±6．4）h。术后住ICU时间（5．1±2．1）d。单因素分析结果显示：术前平均肺动脉压（PAP）增高（P〈0．05）、术前射血分数低（P〈0．05）、体循环心室为右心室（P〈0．05）、分期手术（P〈0．05）、合并腔静脉异位引流（P〈0．05）、术后乳酸（Lac）增高（P〈0．05）、术后中心静脉压（CVP）高（P〈0．05）、术后当天需要大量晶胶体液维持循环稳定（P〈0．05）、术后胸腔引流时间长（P〈0．05）和术后合并感染（P〈0．05）是Fontan类手术患者术后延迟恢复的危险因素。结论Fontan类手术治疗功能性单心室已经取得了很好的近期结果，明确患者手术风险因素，并妥善处理才能缩短患者的恢复进程，使患者获益。

Risk Factors Associated with Prolonged Recovery after Fontan Operation

Objective To analyze risk factors contributing to prolonged postoperative recovery after Fontan operation. Methods Clinical data of 60 patients undergoing Fontan operation between January 2012 and June 2013 in Beijing Fu Wai Hospital were retrospectively analyzed, including their demographic data, preoperative angiography and echocardiogram, and preoperative, intraoperative and postoperative hemodynamic data and blood test results. According to different length of hospital stay （LOS）, all the 60 patients were divided into 2 groups. In the normal recovery group, there were 45 patients including 33 males and 12 females with their age of 5.7±1.7 years,whose LOS was shorter than 32.5 days. In the prolonged recovery group, there were 15 patients including 10 males and 5 females with their age of 4.9±1.6 years, whose LOS was longer than 32.5 days （over 75th percentile of LOS ）. LOS of the 60 patients ranged from 12 to 53 days, and 75th percentile of LOS was 32.5 days. Clinical results were compared between the 2 groups, and risk factors for prolonged postoperative recovery were analyzed. Results Preoperatively, their oxygen saturation by pulse oximetry was 80.5% ±7.4%, ejection fraction （EF） was 64.1% ± 6.6%, Nakata index was 370.6 ±234.2 mm^2/m^2, McGoon ratio was 2.2 ±0.7, and pulmonary arterial pressure （PAP） was 12.4±4.0 mm Hg. Twenty-seven patients （45.0%） received Glenn procedure before Fontan operation at the age of 0.9-4.0 years, and the duration from Glenn procedure to Fontan operation was 1.0-5.1 years. Two patients （3.3%） died after Fontan operation. Cardiopulmonary bypass time of 55 patients who received Fontan operation under parallel circulation was 112.0±52.4 minutes. Aortic cross-clamping time of 5 patients who received concomitant repair of intracardiac anomalies under circulatory arrest was 44.8±9.2 minutes. The duration of mechanical ventilation was 18.8 ±6.4 hours, and ICU stay was 5.1 ±2.1 days. Univariate analysis showed that risk factors for prolonged postoperative recovery included higher preoperative PAP （P 〈 0.05）, lower preoperative EF （P 〈 0.05）, right ventricle as functional single ventricle （P 〈 0.05 ）, previous Glenn procedure history （P 〈 0.05 ）, concomitant total anomalous venous connection （P 〈 0.05）, higher postoperative lactate level （P 〈 0.05 ）, higher postoperative central venous pressure （P 〈 0.05 ）, the need for greater volume of fluid resuscitation during the first 24 hours postoperatively （P 〈 0.05）, long duration of chest drainage （P 〈 0.05 ） and postoperative infection （P 〈 0.05 ）. Conclusion Short-term clinical results of Fontan operation for the treatment of functional single ventricle are satisfactory. Careful assessment and appropriate management of risk factors are helpful to improve postoperative recovery after Fontan operation.