Ekstrakardiyak Fontan Ameliyatı Sonrası Plevral Efüzyon Oluşumunu Etkileyen Risk Faktörleri

Yıl 2022, Cilt: 14 Sayı: 3, 49 - 56, 31.12.2022

Ahmet Bolukçu , Ahmet Can Topçu , Buğra Harmandar

https://doi.org/10.35514/mtd.2022.71

Öz

Giriş: Fontan ameliyatı tek ventrikül fizyolojisi için en sık yapılan ameliyatlardan biridir. Ameliyat sonrasında hastalar, uzamış plevral efüzyon ve başka komplikasyonlar açısından risk altındadır. Bu çalışmada; pulmoner arter basıncının, fenestrasyon yapılıp yapılmamasının, kullanılan ekstrakardiyak greftin çapının ve tromboproflaksi rejimlerinin Fontan ameliyatı sonrası uzamış plevral efüzyon gelişimine olan etkilerini araştırmayı amaçladık.

Metod: Hastane veritabanında Fontan ameliyatı yapılan hastalar araştırıldı. Plevral efüzyon oluşumuna etki edebilecek potansiyel faktörler için lojistik regresyon modeli oluşturuldu.

Bulgular: Toplam 67 hasta çalışmaya dahil edildi. Hastaların ortalama yaşı 63 ay, ortalama kilosu 18 kg'dı. Plevral efüzyon 34 (%51) hastada gelişti. Tromboprofillaksi rejimi açısından değerlendirildiğinde warfarin kullanan 28 (%42) hastanın 19'unda (%68), aspirin kullanan 39 (%58) hastanın ise 15'inde (%38) plevral efüzyon görüldü. Fenestrasyon yapılmayan grupta (43 hastanın 26'sı %60) yapılanlara göre (24 hastanın 8'i %33) plevral efüzyon sıklığı anlamlı olarak daha yüksekti (p=0,03). Lojistik regresyon analizinde, fenestrasyon yapılanlarda daha az (OR, 0,3; 95% CI, 0,1-0,96; p=0,04), buna karşın warfarin kullananlarda ise daha sık (OR, 3,4; 95% CI, 1,1-9,8; p=0,02) plevral efüzyon riski olduğu görüldü. Ameliyat sonrası pulmoner arter basıncı 13 mmHg'ın üzerinde olanlarda plevral efüzyon sıklığı anlamlı olarak daha fazlaydı (p=0,002).
Sonuç: Plevral efüzyon oluşumunun, ameliyat sonrasında pulmoner arter basıncının yüksek olması, warfarin kullanılması ve fenestrasyon yapılmaması ile arttığı görüldü. Greft size indeksi göreceli olarak büyük olanlarda pulmoner arter basıncı daha düşüktü; ancak bu durum plevral efüzyon oluşumuna etki etmedi.

Anahtar Kelimeler

ekstrakardiyak greft, fontan, plevral efüzyon, fenestrasyon, warfarin

Risk factors for pleural effusion after extracardiac Fontan procedure assessment of the commonest Fontan complication

Öz

Objective: Fontan procedure is one of the most performed procedures for single ventricle physiology. After the procedure, patients are at risk for prolonged pleural effusion and other complications. We aimed to investigate the prolonged pleural effusion after Fontan procedure in terms of pulmonary arterial pressure, fenestration, diameter of the extracardiac graft, and thromboprophylaxis regimen.

Methods: Hospital database was searched for the patients who underwent a Fontan operation. A logistic regression analysis model was constructed for pleural effusion.

Results: A total of 67 patients were enrolled in the study. Median age was 63 months, median weight was 18 kg. Pleural effusion occurred in 34 (51%) patients. In terms of thromboprophylaxis regimens, 28 (42%) patients were on warfarin, of those 19 (68%) had pleural effusion. Of 39 (58%) patients who were in aspirin group, 15 had (38%) pleural effusion (p=0.018). Pleural effusion was more frequent in the non-fenestration group (26 of 43, 60% vs. 8 of 24, 33%), significantly (p=0.03). Logistic regression analyses revealed that fenestrated group was less likely to (OR, 0.3; 95% CI, 0.1-0.96; p=0.04) and warfarin group was prone to (OR, 3.4; 95% CI, 1.1-9.8; p=0.02) have pleural effusion. In individuals who had a pulmonary artery pressure higher than 13 mmHg postoperatively, pleural effusion was more frequent (p=0.002).

Conclusion: Pleural effusion occurrence increased with higher postoperative pulmonary artery pressure, warfarin use, and absence of fenestration. Patients with relatively higher graft size index had a lower pulmonary artery pressure, although this is not reflected in pleural effusion occurrence.

Anahtar Kelimeler

fontan, extracardiac graft, pleural effusion, fenestration, warfarin

Kaynakça

• Fontan F, Baudet E. Surgical repair of tricuspid aresia. Thorax.1971;26:240-248. Doi:10.1136/thx.26.3.240.
• Paridon SM, Mitchell PD, Colan SD, Williams RV, Blaufox A, Li JS, et al. A cross-sectional study of exercise performance during the first 2 decades of life after the Fontan operation. Journal of the American College of Cardiology. 2008;52(2):99-107. Doi:10.1016/j.jacc.2008.02.081.
• Monagle P, Cochrane A, Roberts R, Manlhiot C, Weintraub R, Szechtman B, et al. A multicenter, randomized trial comparing heparin/warfarin and acetylsalicylic acid as primary thromboprophylaxis for 2 years after the Fontan procedure in children. Journal of the American College of Cardiology. 2011;58(6):645-651. Doi:10.1016/j. jacc.2011.01.061.
• Giannico S, Hammad F, Amodeo A, Michielon G, Drago F, Turchetta A, et al. Clinical outcome of 193 extracardiac Fontan patients. Journal of the American College of Cardiology. 2006;47(10):2065-2073. Doi: 10.1016/j. jacc.2005.12.065.
• Anderson PAW, Sleeper LA, Mahony L, Colan SD, Atz AM, Breitbart RE, et al. (2008). Contemporary outcomes after the Fontan procedure. Journal of the American College of Cardiology. 2008;52(2):85-98. Doi:10.1016/j. jacc.2008.01.074.
• Gersony DR, Gersony WM. Management of the postoperative Fontan patient. Progress in Pediatric Cardiology.2003;17:73-9. Doi:10.1016/S1058- 9813(03)00011-0.
• Fu S, Feng Z, Dietmar S. Factors influencing pleural effusion after Fontan operation: An analysis with 95 patients. Chinese Medical Sciences Journal. 2010;25(1):38- 43. Doi: 10.1016/S1001-9294(10)60018-1.
• van den Bosch AE, Roos-Hesselink JW, van Domburg R, Bogers AJJC, Simoons ML, Meijboom FJ, et al. Long-term outcome and quality of life in adult patients after the Fontan operation. The American Journal of Cardiology. 2004;93:1141-1145. Doi:10.1016/j.amjcard.2004.01.041.
• Harmandar B. İflas eden Fontan dolaşımı “Güncel cerrahi ve medical tedavi seçenekleri. Journal of Istanbul Faculty of Medicine. 2013;76(4):77-83. Doi:10.18017/itfd.11712.
• Mascio CE, Austin HE. Pleural effusions following the Fontan procedure. Current Opinion in Pulmonary Medicine.2010;16:362-366. Doi:10.1097/ MCP.0b013e3283396efc.
• Haas GS, Hess H, Black M, Onnasch J, Mohr FW, van Son JAM. Extracardiac conduit Fontan procedure: Early and intermediate term results. European Journal of Cardio-thoracic Surgery. 2000;17:648-654. Doi:10.1016/ S1010-7940(00)00433-4.
• François K, Bove T, Groote KD, Panzer J, Vandekerckhove K, Suys B, et al. (2009) Pleural effusions, water balance mediators and the influence of lisinopril after completion Fontan procedures. European Journal of Cardio-thoracic Surgery. 2009;36:57-62. Doi:10.1016/j.ejcts.2009.02.059.
• Bradley SM. Use of a fenestration should be routine during the Fontan procedure: Pro. Pediatric Cardiac Surgery Annual. 2010;13:55-59. Doi:10.1053/j.pcsu.2010.01.004.
• Meadows J, Lang P, Marx G, Rhodes J. Fontan fenestration closure has no acute effect on exercise capacity but improves ventilator response to exercise. Journal of Mamiş ve ark. 8 the American College of Cardiology. 2008;52(2):108-113. Doi:10.1016/j.jacc.2007.12.063.
• Atz AM, Travison TG, McCrindle BW, Mahony L, Quartermain M. Williams RV, et al. Late status of Fontan patients with persistent surgical fenestration. Journal of the American College of Cardiology. 2011;57(4):2437- 2443. Doi:10.1016/j.jacc.2011.01.031.
• Garofalo CA, Cabreriza SE, Quinn TA, Weinberg AD, Printz BF. Hsu DT, et al. Ventricular diastolic stiffness predicts perioperative morbidity and duration of pleural effusions after the Fontan operation. Circulation. 2006;114:I-56-I-61. Doi:10.1161/CIRCULATIONAHA.105.001396.
• van Doorn CA, de Leval MR. The lateral tunnel Fontan. Operative Techniques in Thoracic and Cardiovascular Surgery. 2006;11(2):105-22. Doi: 10.1053/j. optechstcvs.2006.05.001.
• Kim SJ, Kim WH, Lim HG, Lee JY. (2008). Outcome of 200 patients after an extracardiac Fontan procedure. The Journal of Thoracic and Cardiovascular Surgery. 2008;136:108-116. Doi:10.1016/j.jtcvs.2007.12.032.
• Ikai A, Fujimoto Y, Hirose K, Ota N, Tosaka Y, Nakata T, et al. Feasibility of the extracardiac conduit Fontan procedure in patients weighing less than 10 kilograms. The Journal of Thoracic and Cardiovascular Surgery. 2008;135:1145- 1152. Doi:10.1016/j.jtcvs.2007.12.013.
• Sinha P, Zurakowski D, He D, Yerebakan C, Freedenberg V, Moak JP, et al. Intra/extracardiac fenestrated modification leads to lower incidence of arrhythmias after the Fontan operation. The Journal of Thoracic and Cardiovascular Surgery. 2013;145:678-682. Doi:10.1016/j. jtcvs.2012.03.080.
• Jonas RA. Comprehensive surgical management of congenital heart disease. 1st ed. London, Arnold. 2004: 357-85.
• Iyengar AJ, Winlaw DS, Galati JC, Celermajer DS, Wheaton GR. Gentles TL, et al. Trends in Fontan surgery and risk factors for early advers outcomes after Fontan surgery: The Australia and New Zealand Fontan registry experience. The Journal of Thoracic and Cardiovascular Surgery. 2014;148:566-575. Doi:10.1016/j.jtcvs.2013.09.074.
• Earing MG, Cetta F, Driscoll DJ, Mair DD, Hodge DO, Dearani JA, et al. (2005). Long-term results of the Fontan operation for double-inlet left ventricle. The American Journal of Cardiology.2005;96:291-298. Doi:10.1016/j. amjcard.2005.03.061.
• Stephenson EA, Lu M, Berul CI, Etheridge SP, Idriss SF. Margossian R, et al. Arrhythmias in a contemporary Fontan cohort. Journal of the American College of Cardiology. 2010;56(11): 890-896. Doi:10.1016/j.jacc.2010.03.079.
• Shikata F, Yagihara T, Kagisaki K, Hagino I, Shiraishi S, Kobayashi J, et al. Does the off-pump Fontan procedure ameliorate the volume and duration of pleural and peritoneal effusions? European Journal of CardiothoracicSurgery. 2008;34:570-575. Doi:10.1016/j. ejcts.2008.04.053.
• Bokesch PM, Kapural MB, Mossad EB, Cavaglia M, Appachi E, Drummond-Webb JJ. et al. Do peritoneal catheters remove pro-inflammatory cytokines after cardiopulmonary bypass in neonates? The Annals of Thoracic Surgery. 2000;70:639-643. Doi: 10.1016/s0003- 4975(00)01453-3.
• Bartz PJ, Driscoll DJ, Dearani JA, Puga FJ, Danielson GK, O’Leary PW, et al. Early and late results of the modified Fontan operation for heterotaxy syndrome. Journal of the American College of Cardiology. 2006;48(11): 2301-2305. Doi: 10.1016/j.jacc.2006.07.053.
• Tireli E, Ugurlucan M, Basaran M, Kafali E, Harmandar B, et al. Extracardiac Fontan operation without cardiopulmonary bypass. The Journal of Cardiovascular Surgery.2006;47(6):699-704.
• Tansel T, Sayin OA, Ugurlucan M, Dayioglu E, Onursal E. Successful bleomycin pleurodesis in a patient with prolonged pleural effusion after extracardiac Fontan procedure. Journal of Cardiac Surgery. 2006;21(6):585- 586. Doi: 10.1111/j.1540-8191.2006.00303.x.
• Ohuchi H, Yasuda K, Hasegawa S, Miyazaki A, Takamuro M, Yamada O, et al. (2001). Influence of ventricular morphology on aerobic exercise in patients after the Fontan operation. Journal of the American College of Cardiology. 2001;37(7):1967-1974. Doi:10.1016/s0735- 1097(01)01266-9.