シンカ スル ウシン バイパス ジュンカン

Since Fontan’s exploit over 30 years ago, a number of important advances relevant tothe Fontan strategy could be achieved as being variations in the technique of anatomical connectionof the systemic venous circulation to the pulmonary arteries and variations instaging of the Fontan procedure. Innovative Norwood procedure and its concept as a firststage of palliation to Fontan circulation have been equivalent to Fontan’s exploit, and haveproduced the “current” philosophy of pushing patients into Fontan physiology early in lifewith hemi-Fontan procedure or bidirectional Glenn shunt.The aim of the first half of our present study is to determine the optimal size and techniquefor construction of the systemic-to-pulmonary arterial shunt which will provide suitablepulmonary blood flow in first-stage Norwood palliation for hypoplastic left heart syndromein neonates. A prosthesis of 3.0 or 3.5 mm in diameter arising from the brachiocephalicartery would be acceptable and can be recommended for first-stage Norwood palliation insmall infants. Although many complicated factors are concerned in the regulation of pulmonaryblood flow, the fundamental strategy is to create a necessary and minimal systemicto-pulmonary arterial shunt in the first-stage Norwood palliation, and then to proceed swiftlywith a second-stage hemi-Fontan procedure.It remains to be determined whether all children should undergo an intermediate hemi-Fontan procedure or bidirectional Glenn shunt prior to their Fontan completion. In my personalopinion, the several advantages of the hemi-Fontan procedure seem to be weighed againstits disadvantages. It is our current practice to perform an intermediate hemi-Fontanprocedure in staging of the Fontan strategy of the patients with some risk factors. Althoughwe generally have waited 6-8 months after a hemi-Fontan operation for a Fontancompletion, we would like to perform an early Fontan completion a few months after hemi-Fontan procedure to shorten the period of partial Fontan circulation and get nearly normaloxygen saturation. Careful follow-up and further investigation will be necessary to determinethe most optimal management guidelines for the Fontan circulation

遠位弓部大動脈瘤肺動脈穿破

We report an extremely rare case of rupture of an aortic arch aneurysm into the pulmonary artery. An 85-year-old man was visited to our hospital for surgical repair of aortic arch aneurysm. After arrived at hospital, we noticed he suffer from severe congestive heart failure. Chest auscultation indicated Levine III/IV continuous heart murmur. Computed tomography revealed aortic arch aneurysm and aortic dissection of ascending aorta. Echocardiography demonstrated an abnormal shunt flow from aortic arch aneurysm into the pulmonary artery. At surgery, total arch replacement and pulmonary artery reconstruction were performed

遠位弓部大動脈瘤肺動脈穿破

We report an extremely rare case of rupture of an aortic arch aneurysm into the pulmonary artery. An 85-year-old man was visited to our hospital for surgical repair of aortic arch aneurysm. After arrived at hospital, we noticed he suffer from severe congestive heart failure. Chest auscultation indicated Levine III/IV continuous heart murmur. Computed tomography revealed aortic arch aneurysm and aortic dissection of ascending aorta. Echocardiography demonstrated an abnormal shunt flow from aortic arch aneurysm into the pulmonary artery. At surgery, total arch replacement and pulmonary artery reconstruction were performed

チアノーゼ性心疾患に対する肺動脈絞扼術

The early and late results of pulmonary artery banding (PAB) for cyanotic heart defects in early infancy were reviewed. Nine patients were divided into two groups : Group F (five patiens) in which Fontan type repairs were expected as definitive repair in the near future ; Group A (four patients) in which anatomical repairs were programmed in the near future. Six patients had a good early postoperative course, and then consisted of three patients of Group A and three patients of Group F. The band circumference, intraoperative pulmonary-to-systemic systolic pressure ratio and arterial oxygen tension after PAB in the good cases of Group A were 20.0±1.7 mm + 1 mm for each kilogram of the infant's weight, 0.52±0.07 and 46.4±11.3 mmHg respectively. These indices in the good cases of Group F were 21.1±1.7 mm + 1 mm for each kilogram of the infant's weight, 0.55±0.02 and 38.8±1.0 mmHg respectively. The standard deviations of every index for PAB in Group F were small. Three patients of Group A have undergone successful total correction. Intraoperative pulmonary-to-systemic systolic pressure ratio of 0.5 as the index of PAB is preferable to Group A. However, only two patient of Group F were waiting for Fontan type definitive repair. For the patient especially in Group F, careful observation and well-timed staged repair with regard to subaortic stenosis and restrictive atrial septal defect and ventricular septal defect are necessary after accurate PAB as mentioned above

Surgical management of infants with mitral valve stenosis or atresia without diminutive ascending aorta

The surgical strategy in infants with mitral valve stenosis or atresia without diminutive ascending aorta remains to be established, including the potential for biventricular repair as a definitive operation. Our surgical experience of six infants with mitral valve stenosis (4patients) or atresia (2patients) without diminutive ascending aorta was evaluated based on three important factors:left ventricular volume;the nature of the systemic outflow obstruction; and the type of mitral valve anomaly. Two patients with systemic outflow tract diameter less than 65% of normal underwent systemic outflow tract reconstruction, and the other patients with outflow tract diameter more than 68%of normal were able to maintain systemic circulation without repair. Only one patient with mitral valve stenosis without left ventricular outflow tract obstruction underwent a successful open mitral valvotomy as a biventricular repair after first-stage palliation. The left ventricle of the other patients did not grow after first-stage palliation. Due to progressive subaortic narrowing, pulmonary artery banding should be avoided in patients with mitral atresia due to absent atrioventricular connection who are future Fontan candidates. Most patients with this lesion can be expected to become candidates for safe Fontan-type repair