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J Thorac Cardiovasc Surg 1996;111:1291
© 1996 Mosby, Inc.

LETTERS TO THE EDITOR

Location of the conduction tissue in double-inlet left ventricle with leftward rudimentary right ventricle

Jacques A. van Son, MD, Frank L. Hanley, MD

Division of Cardiothoracic Surgery
University of California at San Francisco
San Francisco, CA 94143-0118

Reply to the Editor:

We have read the letter from Dr. Anderson regarding the location of the atrioventricular conduction bundle in(S,L,L} hearts and are in complete agreement with the location of the bundle in these hearts. In fact, we acknowledged Dr. Anderson's excellent work in this area in our article.

We wish to emphasize, however, that we are not confused about the location of the conduction system. The statement that we made in the article that "the nonbranching bundle courses at the superior margin of the BVF [bulboventricular foramen]" refers to the anatomy when viewed from the transatrial approach, that is, from the left ventricular side. This is our preferred approach for examining the BVF, because it is the least destructive.

We are in complete agreement with Dr. Anderson that sometimes it is possible to resect a wedge of tissue from the apical trabecular septum by incising close to the obtuse margin of the ventricular mass. However, more extensive resection is often needed in severely restrictive BVFs, and this is especially more destructive in neonates and small infants. In such patients we prefer to perform a Damus procedure. Furthermore, the intraoperative manipulation necessary to expose the BVF through the rudimentary chamber, the great vessels, or the atrioventricular valve results in substantial distortion. When this problem is combined with the intrinsic fragility of the bundle in patients with{S,L,L} hearts, the risks of conduction injury are high.





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Frank L. Hanley
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