The Fontan operation: experience at Siriraj Hospital.

Seventy five patients underwent modified Fontan operation at Siriraj Hospital from October 1987 to December 1998. Cardiology data was analyzed retrospectively. Four patients' data was unavailable. Median age at operation was 9.7 (1.8-34) years old. Tricuspid atresia accounted for 38 per cent of the patients. Ten patients (14.1%) died in the acute post operative period due to consequence of low cardiac output. Another 3 patients (4.2%) expired in the intermediate and late post operative period. Age at operation, pulmonary artery size, pre-operative oxygen saturation, and mean pre-operative pulmonary artery pressure were not different between those who survived and those who died. Abnormal pulmonary vein, atrioventricular valve regurgitation, and underlying ventricular morphology statistically affected the acute survival of modified Fontan operation. Intraoperative aortic cross clamp time, and post operative mean pulmonary artery pressure on day 0, 1 and 2 post operation were found statistically shorter and lower in the survival group. Survival rate at 5 years was 83 per cent. Modified Fontan operation is the final palliative operation of choice for low risk single ventricle physiology in our institution with acceptable outcome. Thorough pre-operative hemodynamic and anatomic studies and staging modified Fontan procedure may include a higher number of candidates and improve the outcome of the operation.

Early extubation following open heart surgery in pediatric patients with congenital heart diseases.

The study of tracheal extubation time in pediatric patients who underwent open heart surgery was performed in the period of 1990-1991 (group 1) and 1992-May 1994 (group 2), composed of 174 and 208 cases in group 1 and group 2 respectively. The criteria for extubation in these patients are convention regimens with considered subsequent standard of CPB, such as fully rewarmed, hemodynamic stable with adequate cardiac output with low-dose or no inotropes/ vasodilator, without significant dysrhythmias and no significant mediastinal bleeding. The difference of postoperative fluid management between the two groups include the regimens of total fluid intake of two-thirds of daily maintenance fluid in group 1, whereas, the total fluid therapy of group 2 depended on the patients' age and body weight. The results show that, early extubation within 8 hours of ICU arrival were 20.5 per cent and 61.7 per cent in group 1 and group 2 respectively. All of the patients in group 2, after extubation, were discharged to the ward on the first postoperative day. The overnight ventilation was about 74.1 per cent and 30.6 per cent in the first and second groups respectively. The prolonged intubation (more than 24 hours) was almost the same in two groups. There was no significant complication of early extubation with the limitation of daily total fluid intake. The causes of tracheal reintubation in both groups were fluid overload and residual cardiac lesions. The prior etiology occurred in group 1 more than group 2. It was concluded that, after the change in postoperative fluid therapy regimens, early extubation following open-heart pediatric surgery is highly successful with no significant complication. The benefits of early extubation include cost savings, patient comfort, early patient mobilization, improved cardiac function, reduced respiratory complications and reduction of case cancellation due to early ICU discharge.

Surgical treatment for adult congenital heart disease.

A total of 1,408 adult congenital heart disease patients (age over 13 years) underwent surgery between 1979 and 1995 at Siriraj Hospital, contributing 33.75 percent to the overall number of congenital heart disease cases (4,172) who underwent surgery in that period. This finding is similar to statistics in the West. The ages ranged from 13.3 years to 72 years, with a mean of 24.06 years. The oldest patient was a 72 year-old man with coronary cardiac chamber fistula. The most common diagnoses in descending order were: atrial septal defect (41.05 per cent), patent ductus arteriosus (16.19 per cent), tetralogy of Fallot (14.06 per cent) and ventricular septal defect (10.87 per cent). These four categories covered 82 percent of the cases. The overall surgical mortality was 1.78 per cent, compared with 3 per cent in patients who had undergone surgery during childhood. Only patients with double outlet of the right ventricle and congenital aortic stenosis, or left ventricular outflow tract obstruction, showed increased risk of death (20 per cent), compared with 5.77 per cent in those cases who had undergone surgery during childhood. The conclusions drawn from the study are that surgical treatment for adult congenital heart diseases showed a low average of surgical mortality of less than 2 per cent in almost every category except double outlet of the fight ventricle and congenital aortic stenosis, for which early surgery is recommend.

Cardiac surgery at Siriraj Hospital, B.E. 2522-2532.

An eleven year retrospective analysis of patients being treated for heart disease at Siriraj Hospital, during 1979-1989, was carried out in order to find out the epidemiological characteristics of disease and the results of surgical treatment. There were 4289 patients encountered during the period of study. Of these patients, 2565 (60 percent) had congenital heart disease while the rest had the acquired ones. 40 percent of these patients were 13 years and below. Among patients with congenital heart disease, PDA, ASD, Tetralogy of Fallot, and VSD were encounted in 25, 22, 20 and 15 percent respectively. Valvular heart disease, coronary artery disease and pericardial disease were encountered in 56, 15 and 12 percent respectively. The opened heart surgery was carried out in 2753 patients (64 percent) while only 1536 patients (36 percent) had the closed one. The overall mortality following surgery was 3.1 percent. The mortalities among patients with the congenital and the acquired heart disease were 2.03 and 5.22 percent and for those underwent opened and closed surgery were 3.92 and 2.21 percent respectively.