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J Thorac Cardiovasc Surg 2000;120:891-901
© 2000 The American Association for Thoracic Surgery

Surgery for Congenital Heart Disease

Modifications to the cavopulmonary anastomosis do not eliminate early sinus node dysfunction

From the Divisions of Cardiology^a and Cardiothoracic Surgery^b and The Departments of Pediatrics and Surgery, The Children's Hospital of Philadelphia and The University of Pennsylvania School of Medicine, Philadelphia, Pa.

Received for publication May 4, 2000. Revisions requested June 13, 2000; revisions received June 20, 2000. Accepted for publication June 26, 2000. Address for reprints: Mitchell I. Cohen, MD, Division of Pediatric Cardiology, The Children's Hospital of Philadelphia, 34th & Civic Center Blvd, Philadelphia, PA 19104 (E-mail: cohenmi{at}email.chop.edu)

Abstract

Objective: To determine whether operations that theoretically jeopardize the sinus node (hemi-Fontan and/or lateral tunnel Fontan procedures) are associated with a greater risk of sinus node dysfunction than those that theoretically spare the sinus node (bidirectional Glenn and/or extracardiac conduit).
Methods: Between January 1, 1996, and December 31, 1999, a prospective cohort study was conducted evaluating the incidence of sinus node dysfunction in patients undergoing a bidirectional Glenn or hemi-Fontan procedure and those in whom the Fontan repair was completed with either an extracardiac conduit or a lateral tunnel. Sinus node dysfunction was defined (1) as a heart rate more than 2 SD below age-adjusted norms or (2) as a predominant junctional rhythm and/or a sinus pause of more than 3 seconds as determined by the resting electrocardiogram and/or ambulatory monitoring at hospital discharge.
Results: Fifty-one patients had a bidirectional Glenn shunt (mean age 7.8 ± 5.1 months) and 79 a hemi-Fontan procedure (mean age 6.9 ± 2.8 months). The incidence of sinus node dysfunction on postoperative day 1 was significantly higher after the hemi-Fontan (36%) than after the bidirectional Glenn shunt (9.8%); however, by hospital discharge this difference was no longer apparent (hemi-Fontan [8%]; bidirectional Glenn [6%]; P = not significant). No difference in early sinus node dysfunction was discernible after the extracardiac conduit (4/30 [13%]) compared with the lateral tunnel Fontan procedure (6/46 [13%]) (P = not significant). No diagnostic or perioperative variables were predictive of sinus node dysfunction.
Conclusions: Avoidance of surgery near the sinus node has no discernible effect on the development of early sinus node dysfunction. Thus, concerns about early sinus node dysfunction should not override patient anatomy or surgeon preference as determinants of which cavopulmonary anastomosis to perform.

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