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Yıl 2013, Cilt: 76 Sayı: 4, 77 - 83, 21.05.2014

Buğra Harmandar

Öz

Fontan operation broke fresh ground in the treatment of patients with single ventricle anatomy by separating the systemic venous blood from pulmonary venous circulation. Survival rate following Fontan operation improved recently due to the discovery of patient specific factors, modifications in surgical techniques and improvement in postoperative patient care. Failure of Fontan circulation may happen in early or late follow-up period following Fontan operation. Progressive ventricular dysfunction, dysrhythmia, progressive hypoxemia, cyanosis, increase in pulmonary vascular resistance or protein-losing enteropathy may be observed in this patient group which is more frequently encountered at present. Conditions causing failure of Fontan circulation and the surgical or medical treatment options are discussed in this article.

Anahtar Kelimeler

Fontan Single ventricle Protein-losing enteropathy Failing Fontan circulation

Kaynakça

  • Stamm C, Friehs I, Mayer JE, Zurakowski D, Triedman JK, Moran AM, et al. Long-term results of the lateral tunnel Fontan operation. J Thorac Cardiovasc Surg 2001;121:28–41.
  • Mair DD, Puga FJ, Danielson GK. The Fontan procedure for tricuspid atresia: early and late results of a 25-year experience with 216 patients. J Am Coll Cardiol 2001;37:933–9.
  • Burkhart HM, Dearani JA, Mair DD, Warnes CA, Rowland CC, Schaff HV, et al. The modified Fontan procedure: early and late results in 132 adults. J Thorac Cardiovasc Surg 2003;125:1252–9.
  • Gentles TL, Gauvreau K, Mayer JE, Fishberger SB, Burnett J, Colan SD, et al. Functional outcome after the Fontan operation: factors influencing late morbidity. J Thorac Cardiovasc Surg 1997;114:392– 40
  • Sensaki H, Masutani S, Kobayashi J, Kobayashi T, Sasaki N, Asano H, et al. Ventricular afterload and ventricular work in Fontan circulation: comparison with normal two-ventricle circulation and single-ventricle circulation with Blalock– Taussig shunts. Circulation 2002;105:2885–92.
  • Tireli E, Ugurlucan M, Basaran M, Kafali E, Harmandar B, Sayin OA, et al. Extracardiac Fontan operation without cardiopulmonary bypass. J Cardiovasc Surg 2006;47:699–704. de Leval MR, Kilner P, Gewilling M, Bull C. Total cavopulmonary connection: a logical alternative to atriopulmonary connection for complex Fontan operations. J Thorac Cardiovasc Surg 1988;96:682–
  • Miura T, Hiramatsu T, Forbes JM, Mayer JE Jr. Effects of elevated coronary sinus pressure on coronary blood flow and left ventricular function: implications after the Fontan operation. Circulation 1995;92:298–303.
  • Marcelletti CF, Hanley FL, Mavroudis C, McElhinney DB, Abella RF, Marianeschi SM, et al. Revision of previous Fontan connections to total extracardiac cavopulmonary anastomosis: a multicenter experience. J Thorac Cardiovasc Surg 2000;119:340–6.
  • Merten L, Hagler DJ, Sauer U, Somerville J, Gewillig M. Protein losing enteropathy after the Fontan operation: an international multi-center study. J Thorac Cardiovasc Surg 1998;115:1063–73.
  • Gerber TC, Nishimura RA, Holmes DR Jr, Lloyd MA, Zehr KJ, Tajik AJ, et al. Left ventricular and biventricular pacing in congestive heart failure. Mayo Clinic Proc 2001;76:803–12.
  • Sojak V, Mazic U, Cesen M, Schrader J, Danojevic N. Cardiac Resynchronization Therapy for the Failing Fontan Patient. Ann Thorac Surg 2008;85:2136–8.
  • Prêtre R, Häussler A, Bettex D, Genoni M. RightSided Univentricular Cardiac Assistance in a Failing Fontan Circulation. Ann Thorac Surg 2008;86:1018–20. Cardarelli MG, Salim M, Love J, Simone S, Tumulty J, Conway D, et al. Berlin Heart as a Bridge to Recovery for a Failing Fontan. Ann Thorac Surg 2009;87:943-6.
  • Throckmorton AL, Ballman KK, Myers CD, Frankel SH, Brown JW, Rodefeld MD. Performance of a 3Bladed Propeller Pump to Provide Cavopulmonary Assist in the Failing Fontan Circulation. Ann Thorac Surg 2008;86:1343–7. DeLeon SY, Ilbawi MN, Idriss FS, Muster AJ, Gidding SS, Berry TE, et al. Persistent low cardiac output after the Fontan operation: should takedown be considered? J Thorac Cardiovasc Surg 1986;92:402–5. Mayer JE Jr, Bridges ND, Lock JE, Hanley FL, Jonas RA, Castaneda AR. Factors associated with marked reduction in mortality for Fontan operations in patients with single ventricle. J Thorac Cardiovasc Surg 1992;10:444–5.
  • Hoffman TM, Wernovsky G, Atz AM, Kulik TJ, Nelson DP, Chang AC, et al. Efficacy and safety of milrinone in preventing low cardiac output syndrome in infants and children after corrective surgery for congenital heart disease. Circulation 2003;107:996–1002.
  • Sorensen GK, Ramamoorthy C, Lynn AM, French J, Stevenson JG. Hemodynamic effects of amrinone in children after Fontan surgery. Anesth Analg 1996;82:241–6.
  • Cesario D, Clark J, Maisel A. Beneficial effects of intermittent home administration of the inotrope/vasodilator milrinone in patients with endstage congestive heart failure: a preliminary study. Am Heart J 1998;135:121–9.
  • López-Candales A, Vora T, Gibbons W, Carron C, Simmons P, Schwartz J. Symptomatic improvement in patients treated with intermittent infusion of inotropes: a double-blind placebo controlled pilot study. J Med 2002;33:129–46. Pfeffer MA, Braunwald E, Moyé LA, Basta L, Brown EJ Jr, Cuddy TE, et al. Effect of captopril on mortality and morbidity in patients with left ventricular dysfunction after myocardial infarction. Results of the Survival and Ventricular Enlargement trial. The SAVE Investigators. N Engl J Med 1992;327:669-77.
  • Kukin ML. Beta-blockers in chronic heart failure: considerations for selecting an agent. Mayo Clinic Proc 2002;77:1199–206.
  • Bruns LA, Chrisant MK, Lamour JM, Shaddy RE, Pahl E, Blume ED, et al. Carvedilol as therapy in pediatric heart failure: an initial multicenter experience. J Pediatr 2001;138:505–11.
  • Fonarow G. B-type natriuretic peptide: spectrum of application. Nesiritide (recombinant BNP) for heart failure. Heart Failure Rev 2003;8:321–5.
  • Marshall J, Berkenbosch JW, Russo P, Tobias JD. Preliminary experience with nesiritide in the pediatric population. J Intens Care Med 2004;19:164–70.
  • Gewillig M. The Fontan circulation: late functional results. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 1994;6:56–63.
  • Vargas FJ, Mayer JE, Jonas RA, Castaneda AR. Atrioventricular valve repair or replacement in atriopulmonary anastomosis: surgical considerations. Ann Thorac Surg 1987;43:403–5.
  • Freedom RM, Benson LN, Smallhorn JR, Williams WG, Trusler GA, Rowe RD. Subaortic stenosis, the univentricular heart and banding of the pulmonary artery: an analysis of 43 patients with univentricular heart palliated by pulmonary artery banding. Circulation 1986;73:758–64.
  • Kreutzer J, Keane JF, Lock JE, Walsh EP, Jonas RA, Castañeda AR, et al. Conversion of modified Fontan procedure to lateral atrial tunnel cavopulmonary anastomosis. J Thorac Cardiovasc Surg 1996;111:1169–76.
  • Khambadkone S, Li J, de Leval MR, Cullen S, Deanfield JE, Redington AN. Basal pulmonary vascular resistance and nitric oxide responsiveness late after Fontan-type operation. Circulation 2003;107:3204–8.
  • Lévy M, Danel C, Laval AM, Leca F, Vouhé PR, Israël-Biet D. Nitric oxide synthase expression by pulmonary arteries: a predictive marker of Fontan procedure outcome? J Thorac Cardiovasc Surg 2003;125:1083–90.
  • Rothman A, Mayer JE, Freed MD. Treatment of chronic pleural effusions after the Fontan procedure with prednisone. Am J Cardiol 1987;60:408–9.
  • Garson A Jr, Bink-Boelkens M, Hesslein PS, Hordof AJ, Keane JF, Neches WH, et al. Atrial flutter in the young: a collaborative study of 380 cases. J Am Coll Cardiol 1985;6:871–8.
  • Triedman JK, Bergau DM, Saul JP, Epstein MR, Walsh EP. Efficacy of radiofrequency ablation for control of intraatrial reentrant tachycardia in patients with congenital heart disease. J Am Coll Cardiol 1997;30:1032–8.
  • Powell AJ, Gauvreau K, Jenkins KJ, Blume ED, Mayer JE, Lock JE. Perioperative risk factors for development of protein-losing enteropathy following a Fontan procedure. Am J Cardiol 2001;88:1206–9.
  • Rychik J, Spray TL. Strategies to treat protein-losing enteropathy. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2002;5:3–11.
  • Lenz D, Hambsch J, Schneider P, Häusler HJ, Sauer U, Hess J, et al. Protein-losing enteropathy in patients with Fontan circulation: is it triggered by infection? Crit Care 2003;7:185–90.
  • Ringel RE, Peddy SB. Effect of high-dose spironolactone on protein-losing enteropathy in patients with Fontan palliation of complex congenital heart disease. Am J Cardiol 2003;91:1031–2. Stier CT Jr, Koenig S, Lee DY, Chawla M, Frishman WH. Aldosterone and aldosterone antagonism in cardiovascular disease: focus on eplerenone (Inspra). Heart Dis 2003;5:102–18.
  • Therrien J, Webb GD, Gatzoulis MA. Reversal of protein losing enteropathy with prednisone in adults with modified Fontan operations: long term palliation or bridge to cardiac transplantation? Heart 1999;82:241–3.
  • Ghanayem NS, Berger S, Tweddell JS. Medical Management of the Failing Fontan. Pediatr Cardiol 2007;28:465–71.
  • Murch SH, Winyard PJD, Koletzko S, Wehner B, Cheema HA, Risdon RA, et al. Congenital enterocyte heparan sulfate deficiency with massive albumin loss, secretory diarrhea, and malnutrition. Lancet 1996;347:1299–301.
  • Bendayán I, Casaldaliga J, Castelló F, Miró L. Heparin therapy and reversal of protein-losing enteropathy in a case with congenital heart disease. Pediatr Cardiol 2000;21:267–8.
  • Donnelly JP, Rosenthal A, Castle VP, Holmes RD. Reversal of protein-losing enteropathy with heparin therapy in three patients with univentricular hearts and Fontan palliation. J Pediatr 1997;130:474–8.
  • Chakrabarti S, Keeton BR, Salmon AP, Vettukattil JJ. Acquired combined immunodeficiency associated with protein losing enteropathy complicating Fontan operation. Heart 2003;89:1130–1.

İFLAS EDEN FONTAN DOLAŞIMI “GÜNCEL CERRAHİ VE MEDİKAL TEDAVİ SEÇENEKLERİ”

Yıl 2013, Cilt: 76 Sayı: 4, 77 - 83, 21.05.2014

Buğra Harmandar

Öz

Tek ventrikül anatomisine sahip hastalarda uygulanan Fontan operasyonu sistemik venöz kanın pulmoner venöz dolaşımdan ayrılmasını sağlayarak bu hasta grubunun tedavisinde çığır açmıştır. Hastaya spesifik faktörlerin tanımlanması, uygulanan cerrahi tekniklerdeki modifikasyonlar ve ameliyat sonrası bakımdaki ilerlemeler sayesinde günümüzde Fontan operasyonu sonrası sağkalım oranı yükselmiştir. Fontan operasyonu sonrası erken veya geç dönemde Fontan dolaşımının iflası meydana gelebilir. İlerleyici ventriküler disfonksiyon, disritmi, ilerleyici hipoksemi, siyanoz, pulmoner vasküler rezistansta artma veya protein kaybettiren enteropati gelişebilen bu hasta grubu günümüzde daha fazla görülmektedir. Bu makalede Fontan dolaşımının iflasına yol açan nedenler ve bu durumlarda uygulanabilecek cerrahi veya medikal tedavi seçenekleri tartışılmaktadır.

Anahtar Kelimeler

Fontan Tek ventrikül Protein-kaybettiren enteropati İflas eden Fontan dolaşımı

Kaynakça

  • Stamm C, Friehs I, Mayer JE, Zurakowski D, Triedman JK, Moran AM, et al. Long-term results of the lateral tunnel Fontan operation. J Thorac Cardiovasc Surg 2001;121:28–41.
  • Mair DD, Puga FJ, Danielson GK. The Fontan procedure for tricuspid atresia: early and late results of a 25-year experience with 216 patients. J Am Coll Cardiol 2001;37:933–9.
  • Burkhart HM, Dearani JA, Mair DD, Warnes CA, Rowland CC, Schaff HV, et al. The modified Fontan procedure: early and late results in 132 adults. J Thorac Cardiovasc Surg 2003;125:1252–9.
  • Gentles TL, Gauvreau K, Mayer JE, Fishberger SB, Burnett J, Colan SD, et al. Functional outcome after the Fontan operation: factors influencing late morbidity. J Thorac Cardiovasc Surg 1997;114:392– 40
  • Sensaki H, Masutani S, Kobayashi J, Kobayashi T, Sasaki N, Asano H, et al. Ventricular afterload and ventricular work in Fontan circulation: comparison with normal two-ventricle circulation and single-ventricle circulation with Blalock– Taussig shunts. Circulation 2002;105:2885–92.
  • Tireli E, Ugurlucan M, Basaran M, Kafali E, Harmandar B, Sayin OA, et al. Extracardiac Fontan operation without cardiopulmonary bypass. J Cardiovasc Surg 2006;47:699–704. de Leval MR, Kilner P, Gewilling M, Bull C. Total cavopulmonary connection: a logical alternative to atriopulmonary connection for complex Fontan operations. J Thorac Cardiovasc Surg 1988;96:682–
  • Miura T, Hiramatsu T, Forbes JM, Mayer JE Jr. Effects of elevated coronary sinus pressure on coronary blood flow and left ventricular function: implications after the Fontan operation. Circulation 1995;92:298–303.
  • Marcelletti CF, Hanley FL, Mavroudis C, McElhinney DB, Abella RF, Marianeschi SM, et al. Revision of previous Fontan connections to total extracardiac cavopulmonary anastomosis: a multicenter experience. J Thorac Cardiovasc Surg 2000;119:340–6.
  • Merten L, Hagler DJ, Sauer U, Somerville J, Gewillig M. Protein losing enteropathy after the Fontan operation: an international multi-center study. J Thorac Cardiovasc Surg 1998;115:1063–73.
  • Gerber TC, Nishimura RA, Holmes DR Jr, Lloyd MA, Zehr KJ, Tajik AJ, et al. Left ventricular and biventricular pacing in congestive heart failure. Mayo Clinic Proc 2001;76:803–12.
  • Sojak V, Mazic U, Cesen M, Schrader J, Danojevic N. Cardiac Resynchronization Therapy for the Failing Fontan Patient. Ann Thorac Surg 2008;85:2136–8.
  • Prêtre R, Häussler A, Bettex D, Genoni M. RightSided Univentricular Cardiac Assistance in a Failing Fontan Circulation. Ann Thorac Surg 2008;86:1018–20. Cardarelli MG, Salim M, Love J, Simone S, Tumulty J, Conway D, et al. Berlin Heart as a Bridge to Recovery for a Failing Fontan. Ann Thorac Surg 2009;87:943-6.
  • Throckmorton AL, Ballman KK, Myers CD, Frankel SH, Brown JW, Rodefeld MD. Performance of a 3Bladed Propeller Pump to Provide Cavopulmonary Assist in the Failing Fontan Circulation. Ann Thorac Surg 2008;86:1343–7. DeLeon SY, Ilbawi MN, Idriss FS, Muster AJ, Gidding SS, Berry TE, et al. Persistent low cardiac output after the Fontan operation: should takedown be considered? J Thorac Cardiovasc Surg 1986;92:402–5. Mayer JE Jr, Bridges ND, Lock JE, Hanley FL, Jonas RA, Castaneda AR. Factors associated with marked reduction in mortality for Fontan operations in patients with single ventricle. J Thorac Cardiovasc Surg 1992;10:444–5.
  • Hoffman TM, Wernovsky G, Atz AM, Kulik TJ, Nelson DP, Chang AC, et al. Efficacy and safety of milrinone in preventing low cardiac output syndrome in infants and children after corrective surgery for congenital heart disease. Circulation 2003;107:996–1002.
  • Sorensen GK, Ramamoorthy C, Lynn AM, French J, Stevenson JG. Hemodynamic effects of amrinone in children after Fontan surgery. Anesth Analg 1996;82:241–6.
  • Cesario D, Clark J, Maisel A. Beneficial effects of intermittent home administration of the inotrope/vasodilator milrinone in patients with endstage congestive heart failure: a preliminary study. Am Heart J 1998;135:121–9.
  • López-Candales A, Vora T, Gibbons W, Carron C, Simmons P, Schwartz J. Symptomatic improvement in patients treated with intermittent infusion of inotropes: a double-blind placebo controlled pilot study. J Med 2002;33:129–46. Pfeffer MA, Braunwald E, Moyé LA, Basta L, Brown EJ Jr, Cuddy TE, et al. Effect of captopril on mortality and morbidity in patients with left ventricular dysfunction after myocardial infarction. Results of the Survival and Ventricular Enlargement trial. The SAVE Investigators. N Engl J Med 1992;327:669-77.
  • Kukin ML. Beta-blockers in chronic heart failure: considerations for selecting an agent. Mayo Clinic Proc 2002;77:1199–206.
  • Bruns LA, Chrisant MK, Lamour JM, Shaddy RE, Pahl E, Blume ED, et al. Carvedilol as therapy in pediatric heart failure: an initial multicenter experience. J Pediatr 2001;138:505–11.
  • Fonarow G. B-type natriuretic peptide: spectrum of application. Nesiritide (recombinant BNP) for heart failure. Heart Failure Rev 2003;8:321–5.
  • Marshall J, Berkenbosch JW, Russo P, Tobias JD. Preliminary experience with nesiritide in the pediatric population. J Intens Care Med 2004;19:164–70.
  • Gewillig M. The Fontan circulation: late functional results. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 1994;6:56–63.
  • Vargas FJ, Mayer JE, Jonas RA, Castaneda AR. Atrioventricular valve repair or replacement in atriopulmonary anastomosis: surgical considerations. Ann Thorac Surg 1987;43:403–5.
  • Freedom RM, Benson LN, Smallhorn JR, Williams WG, Trusler GA, Rowe RD. Subaortic stenosis, the univentricular heart and banding of the pulmonary artery: an analysis of 43 patients with univentricular heart palliated by pulmonary artery banding. Circulation 1986;73:758–64.
  • Kreutzer J, Keane JF, Lock JE, Walsh EP, Jonas RA, Castañeda AR, et al. Conversion of modified Fontan procedure to lateral atrial tunnel cavopulmonary anastomosis. J Thorac Cardiovasc Surg 1996;111:1169–76.
  • Khambadkone S, Li J, de Leval MR, Cullen S, Deanfield JE, Redington AN. Basal pulmonary vascular resistance and nitric oxide responsiveness late after Fontan-type operation. Circulation 2003;107:3204–8.
  • Lévy M, Danel C, Laval AM, Leca F, Vouhé PR, Israël-Biet D. Nitric oxide synthase expression by pulmonary arteries: a predictive marker of Fontan procedure outcome? J Thorac Cardiovasc Surg 2003;125:1083–90.
  • Rothman A, Mayer JE, Freed MD. Treatment of chronic pleural effusions after the Fontan procedure with prednisone. Am J Cardiol 1987;60:408–9.
  • Garson A Jr, Bink-Boelkens M, Hesslein PS, Hordof AJ, Keane JF, Neches WH, et al. Atrial flutter in the young: a collaborative study of 380 cases. J Am Coll Cardiol 1985;6:871–8.
  • Triedman JK, Bergau DM, Saul JP, Epstein MR, Walsh EP. Efficacy of radiofrequency ablation for control of intraatrial reentrant tachycardia in patients with congenital heart disease. J Am Coll Cardiol 1997;30:1032–8.
  • Powell AJ, Gauvreau K, Jenkins KJ, Blume ED, Mayer JE, Lock JE. Perioperative risk factors for development of protein-losing enteropathy following a Fontan procedure. Am J Cardiol 2001;88:1206–9.
  • Rychik J, Spray TL. Strategies to treat protein-losing enteropathy. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2002;5:3–11.
  • Lenz D, Hambsch J, Schneider P, Häusler HJ, Sauer U, Hess J, et al. Protein-losing enteropathy in patients with Fontan circulation: is it triggered by infection? Crit Care 2003;7:185–90.
  • Ringel RE, Peddy SB. Effect of high-dose spironolactone on protein-losing enteropathy in patients with Fontan palliation of complex congenital heart disease. Am J Cardiol 2003;91:1031–2. Stier CT Jr, Koenig S, Lee DY, Chawla M, Frishman WH. Aldosterone and aldosterone antagonism in cardiovascular disease: focus on eplerenone (Inspra). Heart Dis 2003;5:102–18.
  • Therrien J, Webb GD, Gatzoulis MA. Reversal of protein losing enteropathy with prednisone in adults with modified Fontan operations: long term palliation or bridge to cardiac transplantation? Heart 1999;82:241–3.
  • Ghanayem NS, Berger S, Tweddell JS. Medical Management of the Failing Fontan. Pediatr Cardiol 2007;28:465–71.
  • Murch SH, Winyard PJD, Koletzko S, Wehner B, Cheema HA, Risdon RA, et al. Congenital enterocyte heparan sulfate deficiency with massive albumin loss, secretory diarrhea, and malnutrition. Lancet 1996;347:1299–301.
  • Bendayán I, Casaldaliga J, Castelló F, Miró L. Heparin therapy and reversal of protein-losing enteropathy in a case with congenital heart disease. Pediatr Cardiol 2000;21:267–8.
  • Donnelly JP, Rosenthal A, Castle VP, Holmes RD. Reversal of protein-losing enteropathy with heparin therapy in three patients with univentricular hearts and Fontan palliation. J Pediatr 1997;130:474–8.
  • Chakrabarti S, Keeton BR, Salmon AP, Vettukattil JJ. Acquired combined immunodeficiency associated with protein losing enteropathy complicating Fontan operation. Heart 2003;89:1130–1.
Toplam 40 adet kaynakça vardır.

Ayrıntılar

Birincil Dil Türkçe
Bölüm Derleme
Yazarlar

Buğra Harmandar

Yayımlanma Tarihi 21 Mayıs 2014
Gönderilme Tarihi 1 Haziran 2012
Yayımlandığı Sayı Yıl 2013 Cilt: 76 Sayı: 4

Kaynak Göster

APA Harmandar, B. (2014). İFLAS EDEN FONTAN DOLAŞIMI “GÜNCEL CERRAHİ VE MEDİKAL TEDAVİ SEÇENEKLERİ”. Journal of Istanbul Faculty of Medicine, 76(4), 77-83.
AMA Harmandar B. İFLAS EDEN FONTAN DOLAŞIMI “GÜNCEL CERRAHİ VE MEDİKAL TEDAVİ SEÇENEKLERİ”. İst Tıp Fak Derg. Mayıs 2014;76(4):77-83.
Chicago Harmandar, Buğra. “İFLAS EDEN FONTAN DOLAŞIMI ‘GÜNCEL CERRAHİ VE MEDİKAL TEDAVİ SEÇENEKLERİ’”. Journal of Istanbul Faculty of Medicine 76, sy. 4 (Mayıs 2014): 77-83.
EndNote Harmandar B (01 Mayıs 2014) İFLAS EDEN FONTAN DOLAŞIMI “GÜNCEL CERRAHİ VE MEDİKAL TEDAVİ SEÇENEKLERİ”. Journal of Istanbul Faculty of Medicine 76 4 77–83.
IEEE B. Harmandar, “İFLAS EDEN FONTAN DOLAŞIMI ‘GÜNCEL CERRAHİ VE MEDİKAL TEDAVİ SEÇENEKLERİ’”, İst Tıp Fak Derg, c. 76, sy. 4, ss. 77–83, 2014.
ISNAD Harmandar, Buğra. “İFLAS EDEN FONTAN DOLAŞIMI ‘GÜNCEL CERRAHİ VE MEDİKAL TEDAVİ SEÇENEKLERİ’”. Journal of Istanbul Faculty of Medicine 76/4 (Mayıs 2014), 77-83.
JAMA Harmandar B. İFLAS EDEN FONTAN DOLAŞIMI “GÜNCEL CERRAHİ VE MEDİKAL TEDAVİ SEÇENEKLERİ”. İst Tıp Fak Derg. 2014;76:77–83.
MLA Harmandar, Buğra. “İFLAS EDEN FONTAN DOLAŞIMI ‘GÜNCEL CERRAHİ VE MEDİKAL TEDAVİ SEÇENEKLERİ’”. Journal of Istanbul Faculty of Medicine, c. 76, sy. 4, 2014, ss. 77-83.
Vancouver Harmandar B. İFLAS EDEN FONTAN DOLAŞIMI “GÜNCEL CERRAHİ VE MEDİKAL TEDAVİ SEÇENEKLERİ”. İst Tıp Fak Derg. 2014;76(4):77-83.
 Kapak Resmi İndir

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Addressi: İ.Ü. İstanbul Tıp Fakültesi Dekanlığı, Turgut Özal Cad. 34093 Çapa, Fatih, İstanbul, TÜRKİYE

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