Selective surgical approach for atrioventricular reentrant tachycardia

Abstract

From September 1986 through September 1990, 60 operations were performed in 55 patients (32 male and 23 female; age, 1 to 76 years) for ablation of accessory pathways of atrioventricular reentrant tachycardia; 6 patients had additional cardiac procedures. Between September 1986 and August 1988 the initial surgical approach was exclusively epicardial with adjuvant cryoablation (EPI) in 23 patients (group 1) for a left free wall (LFW) pathway in 11, right free wall (RFW) in 3, posteroseptal (PS) in 7, and anteroseptal in 2. During September 1988 through September 1990, 32 patients (group 2) had the initial surgical approach tailored to the location of the mapped accessory pathway: endocardial approach (ENDO) for LFW in 17 and for juxtanodal pathway in 2, EPI for RFW in 3 and for PS in 9, and combined ENDO and EPI for AS in 1. There was no early or late death in either group. In group 1, 2 patients with LFW pathway had development of recurrent preexcitation in the same compartment requiring ENDO reoperation 10 and 11 months later, 1 with anteroseptal pathway needed immediate ENDO and EPI reoperation, and another with LFW, who required pericardial patch repair of a left atrial tear, had a thromboembolic stroke 2 days later. No serious complications occurred in group 2, but 2 patients with PS required reoperation before discharge for a second accessory pathway in another compartment (1 RFW and 1 LFW). Additionally, 4 patients (2 in each group) had from the beginning ablation of two pathways in different compartments. On complete late follow-up (mean, 28 months) all patients are back to preoperative levels of activity and are free of preexcitation. Our experience indicates that with a selective approach in arrioventricular reentrant tachycardia, based on the location of the pathway and the possibilities and limitations of each technique, LFW pathways are more reproducibly ablated with the ENDO technique, whereas the EPI approach is easier for PS and RFW pathways with equally excellent results.