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J Thorac Cardiovasc Surg 1996;111:1291-1292
© 1996 Mosby, Inc.

LETTERS TO THE EDITOR

Surgical technique and atrial arrhythmias after total cavopulmonary connection

Department of Surgery
Division of Cardiothoracic Surgery
Washington University School of Medicine
St. Louis Children's Hospital, Suite 5W24
One Children's Place
St. Louis, MO 63110

To the Editor:

We read with much interest the report by Hashimoto and associates ¹ in the September 1995 issue of the Journal, in which a method of total cavopulmonary connection with an autogenous intraatrial tunnel was presented. Postoperative atrial arrhythmias are a widely recognized and very troublesome clinical entity after various forms of Fontan repair. ² We have several questions pertaining to the occurrence of postoperative atrial arrhythmias after the technique described in this article.

The authors state that "preserving the crista terminalis and the sinus node and its arteries" prevented the development of postoperative atrial arrhythmias. Sinus node dysfunction and conduction abnormalities related to the crista terminalis have been linked to the genesis of atrial arrhythmias, both in patients who have had the Fontan operation ^3,4 and in naturally occurring human atrial flutter. ⁵ Because we are presently working with an experimental model to elucidate more clearly the electrophysiologic importance of these factors with respect to atrial flutter after the Fontan operation, we are very interested to know whether the authors based their conclusions on previously documented observations or if they have any data to support their contention that these factors directly affected the development of postoperative atrial arrhythmias in their series.

We also have some questions regarding the method by which various components of the conduction system were actually "preserved." With respect to the crista terminalis, it is not clear whether the authors are referring to preservation of longitudinal or transverse cardiac conduction. Their comments imply that avoidance of transverse anatomic disruption of the crista terminalis constitutes "preservation" of this structure. In their surgical technique the authors describe performing a longitudinal incision along the sulcus terminalis. In that the sulcus terminalis represents the medial epicardial edge of the crista terminalis, we would assume that such an approach, through either creating or closing the incision, could create conduction block in the vicinity of the crista terminalis and may also alter preferential longitudinal conduction along it, factors that have both been implicated in the pathogenesis of intraatrial reentrant tachycardias in a variety of experimental investigations ^4,6 and clinical studies. ⁵ In addition, we wonder whether the authors could clarify the superior extent of the atriotomy used. As we interpret the location of the atriotomy used, if extended proximally enough, such an incision would have the potential of causing direct injury to the sinoatrial node, which is located along the rostral portion of the crista terminalis. If, as in the Senning operation, the atriotomy was not made along the sulcus terminalis but rather anterior to it on the right atrial free wall, these problems would be avoided.

Finally, we caution the conclusions that this particular technique prevented the development of postoperative atrial arrhythmias. The follow-up in this small series was very short. Arrhythmia-free survival in this patient population correlates to the length of follow-up, perhaps, as the authors recognized, related to the cumulative effects of prolonged atrial distention and stretch. ⁷ It is only with intermediate and late-term follow-up that any meaningful conclusions in this regard can be reached.

References

1. Hashimoto K, Kurosawa H, Tanaka K, Yamagishi M, Koyanagi K, Shinichi I, et al. Total cavopulmonary connection without the use of prosthetic material: technical considerations and hemodynamic consequences. J Thorac Cardiovasc Surg 1995;110:625-32.[Abstract/Free Full Text]
   
2. Balaji S, Gewillig M, Bull C, deLeval MR, Deanfield JE. Arrhythmias after the Fontan procedure: comparison of total cavopulmonary connection and atriopulmonary connection. Circulation 1987;84(Suppl):III162-7.
   
3. Kürer CC, Tanner CS, Norwood WI, Vetter VL. Perioperative arrhythmias after the Fontan repair. Circulation 1990;82(Suppl):IV190-4.
   
4. Rodefeld MD, Bromberg BI, Schuessler RB, Boineau JP, Cox JL, Huddleston CB. Atrial flutter after lateral tunnel construction in the modified Fontan operation: a canine model. J Thorac Cardiovasc Surg 1996;111:514-26.[Abstract/Free Full Text]
   
5. Olgin J, Kalman J, Fitzpatrick A, Epstein L, Lesh MD. Role of right atrial endocardial structures as barriers to conduction during human type I atrial flutter. Activation and entrainment mapping guided by intracardiac echocardiography. Circulation 1995;92:1839-48.[Abstract/Free Full Text]
   
6. Boineau JP, Schuessler RB, Mooney CR, Miller CB, Wylds AC, Hudson RD, et al. Natural and evoked atrial flutter due to circus movement in dogs: role of abnormal atrial pathways, slow conduction, nonuniform refractory period distribution, and premature beats. Am J Cardiol 1980;45:1167-81.[Medline]
   
7. Fontan F, Kirklin JW, Fernandez G, Costa F, Naftel DC, Tritto F, et al. Outcome after a "perfect" Fontan operation. Circulation 1990;81:1520-36.[Abstract/Free Full Text]
   

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This Article Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Sanjiv K. Gandhi Charles B. Huddleston Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Gandhi, S. K. Articles by Huddleston, C. B. Search for Related Content PubMed Articles by Gandhi, S. K. Articles by Huddleston, C. B.