ASAWA, YOSHIYUKI

BAN, TOSHIHIKO

HIKASA, YORINORI

KAMIYA, TETSURO

KAWAI, JUN

KOIE, HISAAKI

MITANI, HITOSHI

MORI, CHUZO

MUNEYUKI, MANNOSUKE

NIO, KIKUO

SHIROTANI, HITOSHI

TAKEDA, JUN

TAMURA, TOKIO

TATSUTA, NORIKAZU

TSUSHIMI, KUREO

Kyoto University Research Information Repository

Title Total Correction of Tetralogy of Fallot (under ExtracorporealCirculation)Author(s)HIKASA, YORINORI; SHIROTANI, HITOSHI; TSUSHIMI,KUREO; KOIE, HISAAKI; TAKEDA, JUN; TATSUTA,NORIKAZU; KAWAI, JUN; BAN, TOSHIHIKO;MUNEYUKI, MANNOSUKE; ASAWA, YOSHIYUKI; NIO,KIKUO; MITANI, HITOSHI; MORI, CHUZO; TAMURA,TOKIO; KAMIYA, TETSUROCitation日本外科宝函 (1966), 35(4): 719-726Issue Date1966-07-01URL http://hdl.handle.net/2433/207317RightType Departmental Bulletin PaperTextversionpublisherKyoto University719 Total Correction of Tetralogy of Fallot (under Extracorporeal Circulation) by YoRINORI HrKASA, Hnosm SHIROTANI, KuREO TsusHIMI, H1sAAKI Korn, JuN TAKEDA, NoRIKAZU TATSUTA, JuN KAWAI and TosHIHIKO BAN From the 2nd Surgical Division, Kyoto University Medical School (Director: Prof. Dr. CHUJI KIMURA) MANNOSUKE MUNEYUKI, YosHIYUKI AsA w A, K1Kuo N1δ and Hnosm MIT AN! From the Department of An田th白iology,Kyoto University Medical School (Director: Prof. Dr. AKIRA INAMOTo) CHUZO MORI, TOKIO TAMURA and TETSURO KAMIYA From the Department of Pediatri民 KyotoUniversity Medi回 1School (Director: Prof. Dr. HrnEo NAGAI) Received for Publication Apr. 30, 1966 FOREWORD Since safeness of selective heart cooling with coronary perfusion was assured experi-mentally by us one year ago, eight cases of tetralogy of F ALLOT were operated radically in our clinic with selective cardiac arrest induced by the above method, under extracor-poreal circulation. Another twoαses, weighing below nine kilograms were repaired under deep hypothermia employing the surface cooling method (HIKASA-SHIROTANI's method). Altogether ten cases of tetralogy of F ALLOT were operated radically and only one patient expired (Table 1). I. R田ultof Radical Operation of Tetralogy of F ALLOT. 12 11 6/12 Result alive Procedure employed extracorporeal circulation l extracorpor回 Icirculati deep hypothermia ? ? ???? ?? ? ? ? ????Patch teflon teflon Sex 合合Table 1. 15 alive extracorporeal circulation teflon 合14 alive alive 口tracorporealcirculation i alive extra co中oreal口氏ulation I alive J ali dead extracorporea 1 circulation pericard extracorporeal circulation extracorporeal circulation teflon 合合5 7 pericard pericard 合合6 13 alive deep hypothermia pericard pericard pericard 合合合720 日本外科宝函第35巻第4号I. CRITERIA OF DETERMINING SURGICAL INDICATION extracorporeal circulation with the heart lung machine. One case of an infant who was operated under deep hypothermia revealed the PA/ AO ratio of 0.33 (1/3), and was repaired successfully. The possible extension of this indication to elder children is to be considered seriously, and further study挺emsto be needed. Table 2. PA/ AO Ratio of the Case with Tetra logy of F ALLOT on which Radica I Surgery Was Performed. 間 AOratio J Number of Ca間ex~~la~i:real ~i:~J:pcトctrcu atlon 0.30～0.39 。 I 0.40～0.49 。 。0.50～0.59 3 。0.60～心.69 2 。0.70～0.79 0.08～0.89 2 。????? 8 2 The ratio of pulmonary arterial diameter to aortic diameter was measured by means of angiocardiogram. Those showing the ratio above 0.5 were roughly considered as indicat-ing radical surgery. Being prep紅edfor the surgery of radical repair, the patient is placed in FOWLER’s position and exploration of the heart is done. Indication of radical o戸rationis finally confirmed by measuring directly the size of the each vessels. As shown by Table 2, this PA/ AO ratio was above 0.5 in each 四 seof older children who were treated under II. PROCEDURE OF RADICAL OPERATION After the heart is exposed and is measured as described above, complete extracor-poreal circulation is started. Decompression procedure of the left atrium is performed through interatrial septum, opening the right atrium first. Then, selective heart cooling Fig. 1 Circuit of Selective Heart Cooling with Coronary Perfusion H:H田texchanger,Oxy : Oxygenator, P :.Pump, R:R田ervoir, S : Suction pump, Fa : Femoral artey TOTAL CORRECTION OF TETRALOGY OF FALLOT 721 with coronary perfusion is started by the circuit, as shown in Fig. 1. 5～10 cc/kg/ min. of blood which is preparatorally cooled down to 4～5 ° centigrade is thus perfused under the pressure not exceeding 100 mmHg. When complete伺 rdiacarrest is induced, a transverse incision as shown in Fig. 2 is placed to right ventricular wall. The purpose of the right atriotomy is to have a dry field in the right ventricle, by suctioning the return of coronary perfusate, besides making sure of the absence of ASD. Therefore, the right atrium is left open during the manipulation in the right ventricle. Selective coron紅 yperfusion is continued intermittently in the duration of 15 to 20 seconds every ten minutes for the purpose of preventing the elevation of myocardial temperature, restart Fig. 2 Transverse Incision of Right Ventricle of heart beat and occurrence of metabolic (GERBODE) derangement of the myocardium itself. The right ventricle is incised transversely as described above for the purpose of giving least in-jury to the myocardium and of protecting from restenosis of the outflow tract when dos-ing the ventriculotomy wound. In the first three 伺 ses,by resection of stenotic conus, outflow jungle was resected extensively, involving the right ventricular wall, in the extent from considerably central of the right ventricle up to the pulmonary valvular ring area. Extension of this resection was so wide that the total mass of resected muscles weighed averagely eight to ten grams and satisfactory dilatation of the outflow tract was thus at-tempted. Closure of the defect of ventricular septum was done with Teflon cloth which was sutured with about twenty individual stitches (Fig. 3). Postoperatively, in al three αses, blood pressures were not maintained at a level of 15 to 20 cmH20 for venous pressure and 90 to 100 mmHg for arterial pressure, without the help of continuous in-travenous dripping of Isuprel (Fig. 4). Even with the aid of Isuprel, maintenance of blood pr悩 ureto such levels was rather difficult. The amount of blood drained from the thoracotomy tubes totaled to 1,000 to 1,650 cc by the time of removal of the tube. ． Fig. 3 Closure of Ventricular Septa! Defe亡t722 日本外科宝函第35巻第4号C"',u, v •••“ f也、叫・6・－ ti!, ・＜•肺）?????????......・－・..・4・ー・－・・..・、‘－－－・.－・・・・・‘・－4・・・-2 4 6 8 10 12 14 16 18 20 22 24んωCι..ie I.Y. f必，，... ゑ50 ーー』『’－. ，・A・－－・－・・－・ 9・…・・・・h・・4・.A・・‘.........-. 2 4 6 8 1012 14 16 18却 2224仏vuFig. 4 Postoperative Course in Early Cases The amount of fluid retention in the chest四vitythereafter, reached to 7 40 to 1,160 c, thus necessitating puncture and drainage. Case 4 was unfortunately lost during the course of the same operative procedure as the above three cases, due to the injury of left branch of the coronary artery while repairing accidental injury of the pulmonary arterial wal. However, the experience of the above four cases gave us the following suggesti0ns. 1) Attempt of thorough dilatation of the outflow tract tends to invite excessive resection of muscle piec田 andto consequent right heart failure postoperatively. 2) Closure of VSD tends to be unsatisfactory with the use of Teflon cloth due to the possibility of a leakage of blood through its mesh for a time, after suturing. And there also is a tendency of incomplete adaptation of Teflon cloth to the edge of the defect. 3) With GERBODE’s transverse incision, higher possibility of injury of the pulmonic ring ar伺 issuspected when manipulating around that area for dilatation, since operative field goes too deep. So, in al the四S白 afterthe fifth, including those叩 sesrepaired under deep hypothermia, removal of stenotic part around the conus, where stenosis is usually significant, were attempted as circumscribed as possible, when manipulating for the dilatation of the outflow tract. And removal of muscle was carefully performed not to go too far to the central part of the right ventricle. Altogether only about two to three grams of muscle pieces were resected. Pulmonic valve was made visible to the surgeon by being pulled down with a hook and small incisions were placed to each commissures. Then, it was dilated more by means of pulmonic valvular dilator (Fig. 5). Also, for the closure of VSD, a doubled pericardial patch was employed being sutured to the edge of the defect with approximately 20 in-dividual stitches. The use of pericardium as an intracardiac patch material was prefered for the closure of VSD to the use of such prosthetic ones like Teflon cloth, which revealed the above mentioned troubles. Moreover, pericardial patch is consid巴rablyex-tensible and may offer les incidence of postoperative aortic regurgitation. By this techni-que, satisfactory adaptation and complete closure of the defect was intended. At the end TOT AL CORRECTION OF TETRALOGY OF F ALLOT 723 Fig. 5 Dilatation of Pulmonary Valvular Ring Area by Means of Pulmonic Valvular Dilator of extracorporeal circulation, assist perfusion was performed for a time, roughly equivalent to the duration of previous heart aロest. 'With such devices, in al these cases the neces司sity of administering Isuprel and similar drugs postoperatively had disappeared. It became posible to maintain venous pressure below 15 cmH20 and arterial pressure around 120 mmHg (Fig. 6). In addition, the amount of blood drained postoperatively from the tho-racotomy tubes came to remain below 1,000 c. Moreover, the retention of pleural fluid C伺鈴dto occur at al. Furthermore, by such improvements of operative techniques, total by-pas time had come to shorten markedly (Fig. 7). Comparison of oxygen saturation of arterial blood before and after the repair is shown in Fig. 8. After performing dilata-tion of outflow tract in the above manner and while the pericardial patch is being sutured Case, T.H. ち.JN- ゆ－－~150 50 V4-11叫 I加叫-・O-・・・b・- • (tb・s’7・・・・世・・・・『~. ・.1.........ー....…＆・a o-..・－－ A・・，・...150 ? ?100 50 ・・岨・・4・ ι・・・..・a・・・..., .......，・4・h・··•···· 。，．．－ー－－2 4 6 8 10 12 14 16 18 20 22 24 hours Fig. 6 Postoperative Course in Recent Cases 724 日本外科宝函第35巻第4号ロ1in150 120 90 60 30 ． EARLY 仁ASES RECENT CASES Fig. 7 Total-by-pa田 Timein Radical Surgery 。fTetralogy of F ALLOT 10<>1 90 80 70 preop. postop Fig. 8 Arterial Oxygen Saturation befo陀 andafter Surgery to VSD, the aortic clamp, which has been placed for selective coronaηperfusion, is removed, and rewarming of the heart is attempted. By this procedure, the heart beat returned to normal quite smoothly in al cases without need of employing electric shock. The right ventriculotomy wound is closed by individual mattress, then over and over sutures. Extubation of the left auricular decompression cannula, closure of the interatrial hole through which this cannula has been inserted, then closure of right atriotomy wound are performed. And the radical operation is accomplished. Due to the need of considerably long-term extracorporeal perfusion, enough attention is paid to the following points. 1) The patient is placed on FOWLER’s position and at圃tention is paid to SVC pressure, not to exceed 30 cmH20 at most, during the entire course of perfusion. 2) The suction system contributes to the cause of marked destruc-tion of the blood. So, the decompression system of the left atrium is used as much as possible, instead. 3) Before and after extracorporeal circulation, maintenance of a normal acid base balance is to be attempted by positive and negative pressure breathing by re-spirator. In addition, during extracorporeal circulation, 4% natrium t】icarbonatesolution was added in an adequate amount and it was deliberately attempted to maintain a normal acid base balance. This solution was administered as a rule, by the amount of 1.0 cc/kg for _the depression of 0.05 of blood pH. 4) Moreover, for the pu叩oseof preventing the occurrence of renal shut down, mannitol was added preliminary into the priming blood at the amount of two grams per one kilogram of the patient’s body weight. In addition, for the radical operation of tetralogy of FALLOT, the following points are deliberately considered. 1) In this malformation, collateral circulation from bronchial artery system is usually developed. Therefore, it is necessary to notice well that a large amount 725 TOTAL CORRECTION OF TETRALOGY OF FALLOT ??? ?， 、． ． ???? ??????，?，?? ?←?17PHCS . h ・Jm戸ayr勺ー川． ． ． ?． ． － ． Sト201110~ ． ． ． ． ． ?? ??． JO ,T ，． ． ． IOllO" 5 VSD Fig. 10 Throm民cyteCount in the Blood (Com-pari回nbetween TF Group and VSD Group) TF VSD Fig. 9 R田ultof ACTH-T田t,Performed before Surgery. (Comparison betw田nTF Group and VSD Group) TF of blood es田pesthrough this circulation system when performing extracorporeal perfusion. From this standpoint, heart lung by-pass currently has been done with such high flow volume as 120 cc/kg/min.. And it was attempted to maintain the mean arterial pressure above 60 mmHg and venous pr＇回surepreferably below 20 cmH20. 2) In this malforma-tion, the cases with hypoadrenocortical function are occasionally seen (Fig. 9). So, if needed, the administration of hydrocortison for two or three postoperative days is to be remembered. 3) Also,. as a characteristics of tetralogy of FALLOT, a decrease of throm-bocyte count in the blood below 100,000, is occasionally seen (Fig. 10). So, a prelimi-nary administration of Vitamin K1 preparation before the operation is to be done sufficiently. Moreover, lpsilon （ε”Aminocaproic acid) and P V P are always added in priming blood at the amount of one volume for ten volumes of fresh blood and extracorporeal circulation is performed with it. Postoperatively, if needed, such hemostatic drugs like Vitamin K1 preparation, lpsilon, Thromboplastin preparation, Fibrinogen, and so on are used. 4) It is assumed by us, that dilution of priming blood with low molecular dextran or amino acid鈎lutionis to be avoided. Because, in tetralogy of F ALLOT, even though there exists a concentration of blood, such changes like decrease of thrombocyte count is already ~en preoperatively. Consequently bleeding tendency is rather manifest compared with the other congenital heart diseases. 5) As to supplying fluid, 500 cc/m2 of fluid was given posto・peratively in 24 hrs. following the way which STURTZ and others recommended. In the next and following 24 hours periods, 750 cc/m2 of fluid was given in each period. For this purpose, 10% D/W was used. 6) In every case, pericardial space was opened enough 726 日本外科宝函第35巻第4号to right chest回 vityby dividing both right pericardium and mediastinal pleura in sufficient length. Thoracotomy tubes were inserted not only to the anterior mediastinum but also to the right chest cavity and continuous postoperative drainage was attempted. IV. SUMMARY As was described above, since the indication for radical operation of tetralogy of F ALLOT and the technique of selective heart cooling by coronary perfusion were established experimentally in our department one year ago, ten 回 sesof tetralogy of F ALLOT were operated radically. Among them only one case was lost, and this result seems roughly Table .3. Findings before and after Surgery. [ Befー らIAfter op. IErythrocytel 648 x 1Q4 I 459 x 104 Blood Cel Count I ! ¥ I Ht I 50.5% I 44% Arterial Oxygen Satu刷 .onI 75.2% i 94.6% CF.A.) I i CircL•lat略 B刷 volume I 2引 I3.62 z (Age : 19 yr., Sex：♀， Weight : 50匂）satisfactory. So, the course of improvement and progress which enabled this result, was discussed mainly in relation with operative procedures. After this series of operation, a 19 year old girl was operated on tetralogy of F ALIβT in our department. Her pulmonary artery was very small, and PA/ AO diametric ratio revealed 1/3 at the time of surgery (R→L shunt: 66%). Defects were successfully re-paired and she took uneventful postoperative course (Table 3). We are now coming to have an impression that our present criteria for surgical indication as mentioned early in this report, may be revised. REFERENCES 1) Abe, K. : Experimental studies on bleeding diathesis not uncommonly accompanied with extracorpor田lcir-culation Arch. Jap. Chirurgie, 31 : 431, 1962. 2) Ban, T. : Uber Blutgerinnungsst凸rungenbeim extrakorporalen Kreislauf, mit be田ndererBerucksichtigung der Frage d白 Perfusionsblut白 unddes gefahrlosen Durchfilhrens der langeren Perfusion. Arch. Jap. Chirur-gie, 35 : 1966 (to be published). 3) Bahnson, H. T. et al. : Surgical tr回tmentand follow-up of 147回S田 oftetra logy of F alot treated by correction. J. Thorac. Cardiovasc. Surg., 44 : 419, 1962. 4) Ehrenhaft, J. L. et al. : Evaluation of results after correction of tetralogy of Falot. J. Thorac. Cardiovasc. Surg., 45 : 224, 1963. 5) Kirklin, J. W. et al. : Factors affecting survival after open operation for tetralogy of Folot. Ann. Surg .152 : 485, 1960. 6) Klinner, W. : Operativ-technische Probleme der Radikaloperation bei Fallotscher Tetralogie. Thoraxchirurgie, 9 : 274, 1961. 7) Klinner, W. : Klinische und experimentelle Untersuchungen zur operativen Korrektur der Fallotschen T＜← tralogie. Ergebnisse der Chirurgie und Orthop詰die,44 : 58, 1962. 8) Lilehei, C. W. et al. : Complete anatomic correction of the tetralogy of Fallot defec匂 Arch.Surg., 73 : 526, 1956. 9) Kirklin, J. W. et al. : Su弔問ltreatment for the tetralogy of Fallot by open intracardiac repair. J. Thorac. Surg., 37 : 22, 1959. 10) Malm, J. R. et al. : An evaluation of total correction of tetralogy of Falot. Circulation, 27 : 805, 1963. 11) Ro詰， D N. : The surgical treatment of Fallot’s tetralogy. Thoraxchirurgie, 9 : 267, 1961. 12) Tsushimi, K. : Experimental and clinical studi白 onopen heart surgery using blood str田mcoling. Arch. Jap. Chirurgie, 34 : 704, 1965. 13) Zerbini, E. J. et al. : Total correction of complex of Fallot under extracor伊realcirculation : Immediate results in a group of 221 patients. J. Thorac. Cardiovasc. Surg., 49 : 430, 1965. 

フアロー氏四徴症に対する根治手術の経験

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フアロー氏四徴症に対する根治手術の経験

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