Incidence Of Sinus Node Dysfunction Research Articles

Sinus node dysfunction and related permanent pacemaker implantation after major cardiac surgeries, systematic review, and meta-analysis.

There is no concise evidence or clinical guidelines regarding the incidence of sinus node dysfunction (SND) and permanent pacemaker (PPM) implantation following cardiac surgeries and their management approaches. We aim to systematically review current evidence on the prevalence of SND, PPM implantation concerning it, and its risk factors in patients undergoing cardiac surgery. Four electronic databases (Cochrane Library, Medline, SCOPUS, and Web of Science) were systematically searched for articles regarding SND after cardiovascular surgeries and reviewed by two independent researchers, and a third review in case of discrepancies. Using the random-effects model, a proportion meta-analysis was performed on data regarding PPM implantation. Subgroup analysis was performed for different interventions, and the possible effect of different covariates was evaluated using meta-regression. From the initial 2012 unique records, 87 were included in the study, and results were extracted. Pooled data from 38,519 patients indicated that the overall prevalence of PPM implantation due to SND after cardiac surgery was 2.87% (95% CI [2.09; 3.76]). The incidence of PPM implantation in the first post-surgical month was 2.707% (95% CI [1.657; 3.952]). Among the four main intervention groups, including valve, maze, valve-maze, and combined surgeries, maze surgery was associated with the highest prevalence (4.93%; CI [3.24; 6.92]). The pooled prevalence of SND among studies was 13.71% (95% CI [8.13; 20.33]). No significant relationship was observed between PPM implantation and age, gender, cardiopulmonary bypass time, or aortic cross-clamp time. Based on the present report, patients undergoing the maze and maze-valve procedures are at higher risk of post-op SND, whereas lone valve surgery had the lowest prevalence of PPM implantation. PROSPERO (CRD42022341896).

Symptomatic Bradycardia In CAD Patient: Which One First To Treat?

Background: The incidence of sinus node dysfunction (SND) increases with age. Likewise, the incidence of coronary artery disease (CAD) has increased from year to year in Indonesia. When doctors are faced SND patients with CAD, it can be confusing in determining initial treatment options. Objective: This study aimed to describe the diagnosis and management of SND in CAD patient. Case Presentation: We will discuss a 75 years old male who had schedule to management of bradycardia symptomatic related to SND. Five month before admission, he had acute coronary syndrome, and had 2 DES implantation at left main (LM) to proximal left anterior descendent (LAD) artery and mid LAD. Two months after PCI he felt near syncope with bradycardia. Evaluation with ambulatory EKG was performed with result of SND, and correction of reversible cause related to SND already done. Eventually, symptom still exist and PPM insertion was decided to perform. Conclusion: Patients with SND and CAD have a higher risk of complications and death. Correction of reversible factors, one of which is CAD, can be done as an initial step in the treatment of SND. When symptomatic signs still appear after correction of reversible causes, PPM implantation is the modality of choice in management.

Preoperative Screening 12-Lead Electrocardiogram Reveals Correctable Cardiac Conditions.

Scenario: This is a preoperative screening 12-lead electrocardiogram (ECG) from a 68-year-old woman scheduled for an outpatient endoscopic procedure under deep propofol sedation. Her only significant medical conditions were obesity and hypertension managed with thiazide diuretics. After the ECG was interpreted, she was asked if she ever experienced symptoms including dizziness, and she reported that she had recently experienced episodes of dizziness but it had been an extremely hot summer so she thought she might be a little dehydrated.Normal sinus rhythm at 75 beats per minute with 2 episodes of sinus node pause (see arrows).The sinoatrial node is the dominate pacer in the heart, and sinoatrial node pauses fall under the category of sinus node dysfunction (SND). Although the pause is not long enough to generate an escape rhythm (3 or more beats from a latent or backup pacer such as the atrioventricular junction or the ventricles); the pause is repeated twice in this 10-second recording. Given the well-designed structure of the sinoatrial node in the right atrium, most SND conditions are acquired as a result of myocardial ischemia, inflammation, excessive vagal tone, sleep apnea, and some medications. In the United States, the incidence of SND is approximately 1 in 600 cardiac patients older than 65 years. Even today, pacemaking activity that originates from the sinoatrial node is not completely understood.If pauses continue for longer than 2 seconds, then the cardiac rhythm is called sinus arrest, and if no other pacemaker cells begin pacing (ie, no escape rhythm occurs) during an episode of sinus arrest, it becomes a cardiac arrest, which is an emergency. If the cardiac arrest occurs out of the hospital, the survival rate is only 10% and the rate of survival with functional neurological function decreases to 8%. Thus, given her symptoms of dizziness, her outpatient endoscopic procedure should be delayed until a cardiac workup has been completed. Asymptomatic patients usually do not require treatment; however, among symptomatic patients, any offending medication may be stopped or a permanent pacemaker is placed to avoid unnecessary cardiac arrest. In this case, the patient had a permanent pacer transvenously placed during a minimally invasive procedure; the following month, she completed her originally scheduled outpatient endoscopic study without complications.

P696Incidence of sinus node dysfunction with cancer chemotherapy: a systematic review of literature

Abstract Background Introduction of newer classes of chemotherapeutic agents has led to improved survival in many cancers, often at the cost of increased side effects. With the advent of cardio-oncology, there has been growing focus on cardiac side effects of chemotherapy like cardiomyopathy, QT prolongation, VT and AF. However, data on cancer chemotherapy related sinus node dysfunction (SND) is limited. Objective To assess the incidence of chemotherapy related SND through a systematic review of available literature. Methods We performed a systematic review of PUBMED database for studies reporting SND (including sinus bradycardia, sinus pauses, sinoatrial exit blocks or asystole) with use of chemotherapeutic agents. Weighted average incidence of SND was calculated from studies. Case reports were reported independently. Results 2012 articles were reviewed of which 38 were eligible for data extraction. Incidence of SND varied significantly between drug classes. However, specific drugs were associated with increased incidence of SND like anthracyclines (Epirubicin 8.3%), antimetabolites (5 Fluorouracil 20%), tyrosine kinase inhibitors (crizotinib 43%), antimicrotubule agents (paclitaxel 29%) and angiogenesis inhibitors (Thalidomide 22%). The weighted average incidence is shown in table. Drug type Drug Type of cancers No. of studies Total No. Weighted average of incidence of sinus arrhythmias No. of case reports Anthracyclines Epirubicin Breast, Hodgkin's disease 1 24 8.3% 1 Idarubicin CML – – – 1 Unclassified anthracyclines Ewing sarcoma 2 370 4.31% – Antimetabolites 5 Fluorouracil Esophageal, gastric, colon, rectal 1 5 20% 1 Capecitabine Rectal cancer – – – 1 Methotrexate Osteosarcoma – – – 1 Cytarabine AML – – – 1 Antimicrotubule agent Paclitaxel Ovarian cancer 2 4505 29.36% – Kinase inhibitors Crizotinib Lung 2 1095 43% 4 Alectinib Lung 1 225 5% – Ibrutinib Mantle cell lymphoma – – – 1 Monoclonal antibodies Infliximab Ulcerative colitis – – – 1 Angiogenesis inhibitors Thalidomide Multiple myeloma 4 83 21.62% 2 Endostar Metastatic colorectal and gastric 1 23 13% – Selective estrogen modulators Tamoxifene Extracranial meningioma – – – 1 Antiandrogen Abiraterone Prostate cancer 1 17 6% – Other drugs Crisnatol mesylate Advanced solid tumors 1 43 2.3% – Mitoxantrone AML – – – 1 Combination drugs Bevacizumab +Vorinostat Malignant Glioma 1 40 3% – All-trans-retinoic acid+idarubicin AML – – – 2 Tivantinib+Erlotinib Advanced solid malignancies 1 32 23.1% – Paclitaxel+Carboplatin+Bevacizumab Lung – – – 1 Paclitaxel+Carboplatin Ovarian 1 79 2.9% – Daunorubicin+Amsacrine AML – – – 1 CHOP Diffuse large B cell lymphoma – – – 1 Conclusion There is cumulative evidence of increased incidence of SND with certain chemotherapeutics. In pre-existing SND, certain drugs and combinations must be avoided and alternative agents, should be considered. Future studies are needed to evaluate the role of remote cardiac monitoring and permanent pacing in specific situations where no safer alternatives exist.

Safety and prognostic value of regadenoson stress cardiovascular magnetic resonance imaging in heart transplant recipients

BackgroundThere is a critical need for non-invasive methods to detect coronary allograft vasculopathy and to risk stratify heart transplant recipients. Vasodilator stress testing using cardiovascular magnetic resonance imaging (CMR) is a promising technique for this purpose. We aimed to evaluate the safety and the prognostic value of regadenoson stress CMR in heart transplant recipients.MethodsTo evaluate the safety, we assessed adverse effects in a retrospective matched cohort study of consecutive heart transplant recipients who underwent regadenoson stress CMR matched in a 2:1 ratio to age- and gender-matched non-heart transplant patients. To evaluate the prognostic value, we compared the outcomes of patients with abnormal vs. normal regadenoson stress CMRs using a composite endpoint of myocardial infarction, percutaneous intervention, cardiac hospitalization, retransplantation or death.ResultsFor the safety analysis, 234 regadenoson stress CMR studies were included - 78 performed in 57 heart transplant recipients and 156 performed in non-heart transplant patients. Those in heart transplant recipients were performed at a median of 2.74 years after transplantation. Thirty-four (44%) CMR studies were performed in the first two years after heart transplantation. There were no differences in the rates of adverse effects between heart transplant recipients and non-heart transplant patients. To study the prognostic value of regadenoson stress CMRs, 20 heart transplant recipients with abnormal regadenoson stress CMRs were compared to 37 with normal regadenoson stress CMRs. An abnormal regadenoson stress CMR was associated with a significantly higher incidence of the composite endpoint compared with a normal regadenoson stress CMR (3-year cumulative incidence estimates of 32.1% vs. 12.7%, p = 0.034).ConclusionsRegadenoson stress CMR is safe and well tolerated in heart transplant recipients, with no incidence of sinus node dysfunction or high-degree atrioventricular block, including in the first two years after heart transplantation. An abnormal regadenoson stress CMR identifies heart transplant recipients at a higher risk for major adverse cardiovascular events.

A left atrial versus a biatrial lesion set for persistent atrial fibrillation ablation during open heart surgery.

To compare the outcomes of left atrial ablation and biatrial (BA) ablation in patients with persistent and long-standing persistent atrial fibrillation undergoing open heart surgery. Between January 2007 and December 2016, 588 consecutive patients with either persistent (20.9%) or long-standing persistent atrial fibrillation (79.1%) were enrolled in this study. To reduce between-group differences, propensity score-matched groups (156 patients/group) were obtained, with similar preoperative and perioperative characteristics. The propensity score-matched left atrial and BA groups did not differ regarding 30-day mortality (1.9% vs 0.6%; P = 0.617), 5-year overall survival (93.5 ± 2.2% vs 92.8 ± 2.9%, P = 0.998) or survival free from thromboembolic events (97.1 ± 2.8% vs 96.2 ± 2.7%, P = 0.309). The BA lesion set was more beneficial in terms of freedom from atrial arrhythmia recurrence (85.3 ± 4.5% vs 91.9 ± 3.1%, P = 0.049; hazard ratio 3.26; 95% confidence interval 1.33-7.99), but it was associated with higher pacemaker implantation rate (3.8% vs 17.3%; P < 0.001) due to sinus node dysfunction. There was no significant between-group difference regarding the incidence of atrioventricular conduction disturbances (3.2% vs 7.0%, respectively; P = 0.211). The 2 lesion sets (left atrial and BA) are associated with similar 30-day mortality, survival rates, incidences of embolic events and atrioventricular conduction disturbances. In patients with persistent atrial fibrillation, concomitant surgical ablation with BA lesion set provided better freedom from atrial arrhythmia recurrence, but BA ablation was associated with a higher incidence of sinus node dysfunction and a higher rate of pacemaker implantation.

Incidence of sinus node dysfunction in patients with long-standing, persistent atrial fibrillation who require simultaneous surgical correction of mitral and tricuspid valve defects and the "Maze IIIB" procedure

Atrial fibrillation (AF) is the most common disorder of heart rhythm. A series of "Maze" surgery was developed, among which the "Maze III" modification is presently a gold standard for surgical treatment of AF. To study the sinoatrial node (SAN) function before and after the "Maze III" surgery. The study included 100 patients (48 males) with persistent and long-standing persistent AF and valve abnormality. Mean age of patients was 59 years and mean AF duration - 4 years. Tachysystolic AF prevailed (62 %); normosystolic AF was observed in 31 % of patients; and bradysystolic - in 7 % of patients. Electric cardioversion was performed for all patients according to the standard method. After successful recovery of the sinus rhythm, the endocardial electrophysiological study (EPS) of the heart was performed. Correction of valve pathology and the "Maze IIIB" surgery were performed on days 1-2 following EPS. The SAN function was evaluated by the time of function recovery (SAN TFR). Using electric cardioversion, the sinus rhythm was restored in all patients. EPS showed abnormal prolongation of the corrected time for the SAN function recovery (CTSANFR) and sinoatrial conduction time (SACT) in 11 % of patients. In 2 % of patients, the abnormal prolongation of SACT was an isolated conduction disorder. In total, 13 % of patients had SAN dysfunction (SAND). These patients received implantable electric cardioverters after a surgical intervention (correction of valve abnormality and "Maze III"). The sinus rhythm recovered immediately after the surgery. On day 7, steady sinus rhythm was observed in 46 % of patients. During the postperfusion period and on the first day postsurgery, 62 % of patients had replacement atrioventricular nodal rhythm. By the time of discharge from the hospital, the nodal rhythm was observed in 25 % of patients. Starting from day 2, the replacement atrial rhythm developed in 13 % of patients, and by the time of discharge from the hospital, 24 % of patients had a stable atrial rhythm. Effectiveness of the surgical treatment for persistent and long-standing persistent AF (modified "Maze IIIB" surgery with simultaneous correction of the mitral valve (MV) and the tricuspid valve (TV)) in the early postsurgery period was 95 %. According to data of preoperative endocardial EPS, SAND was observed in 13 % of patients. Following the surgical correction of MV and TV defects and the criomodification of the "Maze IIIB" surgery, signs of SAND requiring implantation of an electric cardioverter were observed in a total of 24 % of patients.

Comprehensive rhythm evaluation in a large contemporary Fontan population.

Rhythm disturbances are an important cause of morbidity in Fontan patients. Currently, the total cavopulmonary connection is performed by using the intra-atrial lateral tunnel (ILT) ('baffle ILT' or 'prosthetic ILT'), or the extracardiac conduit (ECC). The aim of the study was to evaluate rhythm abnormalities and compare the surgical techniques in a contemporary cohort. In a cross-sectional multicentre study, 115 patients (age 12.5 ± 3.1 years) underwent rhythm evaluation using ECG, exercise testing and Holter, including heart rate variability. Medical history was reviewed for episodes of arrhythmia. Sinus node dysfunction (SND) was found in 29%, 3 of whom required pacemaker therapy. No difference was found in the incidence of SND between ILT and ECC patients. Sinus pauses occurred only in the ILT group. Exercise testing showed no difference in peak heart rate between the groups. Heart rate reserve (P = 0.023) and heart rate recovery (HRrecovery) (P < 0.001) were lower in ILT patients. Atrial arrhythmias were more common in ILT patients (15 vs 1%, P = 0.004), but only in those with a baffle ILT. One patient had symptomatic ventricular tachycardia (VT). Holter recordings showed sub-clinical VT in 6% of patients, which was associated with larger end-diastolic (P = 0.035) and end-systolic volumes (P = 0.029). The overall incidence of arrhythmia was low, although SND was frequently present in both Fontan groups. ILT patients had slower HRrecovery, and ILT patients with the more extensive baffle technique had more atrial arrhythmias and more sinus pauses. The significance of asymptomatic ventricular arrhythmias in this young population remains to be determined.

Single-patch, 2-patch, and caval division techniques for repair of partial anomalous pulmonary venous connections: Does it matter?

We reviewed our experience with the single-patch, 2-patch, and caval division techniques for repair of a partial anomalous pulmonary venous connection. From 1990 to 2009, 124 patients (65 male patients; 52%) were identified. The single-patch, two-patch, and caval division technique was used in 60 (49%), 24 (19%), and 40 (32%) patients, respectively. The median age was 34.5 years (range, 1-76). Of the 124 patients, 99 (80%) had an atrial septal defect. There was no early mortality. Survival at 5, 10, and 15 years was 99%, 95%, and 82%, respectively. One patient (3%) in the caval division group required early reoperation for superior vena caval obstruction. All patients, exept for 3, had regained sinus rhythm at discharge. Late superior vena caval obstruction developed in 3 patients (7.5%) in the caval division group, 3 (5%) in the single-patch group, and 1 (4%) in the 2-patch group (Р = .5). Two patients underwent reoperation for late pulmonary vein obstruction: 1 (2%) in the single-patch group and 1 (4%) in the 2-patch group (P = .08). A permanent pacemaker was required in 3 patients (3%). Surgical treatment of partial anomalous pulmonary venous connections is associated with excellent outcomes. The overall incidence of late superior vena caval or pulmonary vein stenosis is low. Although not significant, the 2-patch technique might be associated with a greater incidence of sinus node dysfunction and late pulmonary venous stenosis. The late development of superior vena caval obstruction is a concern with all techniques, necessitating close follow-up.

306 20 years of follow-up in 132 Senning procedures: late results

Senning procedure was performed for the first time in France at Bordeaux University Hospital in 1965. Follow up have come out focusing on failing systemic right ventricle and rhythmic complication. The aim of this work is to identify prognosis factors of reoperation, arrhythmias and right ventricular dysfunction. This single institution study is a retrospective analysis of 132 patients, with simple (105 patients) and complex (27 patients) transposition of the great arteries, after a Senning procedure between 1977 and 2004. The mean follow-up time was 19.5 ± 6.6 years. Conventional follow up and testing were performed in the same unit. An isotopic ventriculography or MRI was done for 70 patients to investigate the systemic right ventricular function. Operative mortality was 5.3%. Late mortality was 9.6%. 9 patients underwent a single reoperation and one needs heart transplantation. Actuarial survival rate was 91.5%, 91%, 89% and 88% at respectively 1, 5, 10, and 20 years. There is no statistically difference between simple and complex transposition for actuarial survival rate, maintaining permanent sinus rhythm or arrhythmias occurrence. After 20 years of 98% of patients in simple transposition group have ejection fraction > 40% versus 58% in complex transposition (p<0.001). Risk factors of ventricular dysfunction were complex transposition (p<0.001) and absence of cardioplegia (p<0.001). Last follow-up showed 91% in NYHA class 1. Imaging systemic right ventricular dysfunction (FEVD<40%) was yet uncommon at 20 years of follow-up but is not sufficient to predict a good response of this ventricle to stress and effort. Long term follow-up after the Senning operation shows frequent and increasing incidence of sinus node dysfunction and others arrhythmias: these complications are expected in double switch procedure.

Sinus Node Dysfunction after Catheter Ablation of Persistent Atrial Fibrillation: The Incidence and Clinical Characteristics

Introduction: Sinus node dysfunction (SND) and atrial fibrillation (AF) often coexist. In patients with persistent AF, restoration of sinus rhythm by catheter ablation may unmask SND, thereby requiring pacemaker therapy after the ablation. However, the incidence of SND after catheter ablation of persistent AF is unknown. Methods: Seven hundred-forty consecutive patients (634 males, 60±10 years) who underwent ablation for persistent or longstanding persistent AF from 2008 to 2010 at our institute were studied. SND after the ablation which required pacemaker implantation during 6 months follow-up was determined. Results: Seven patients (1%) underwent pacemaker implantation for SND at median of 28.5 days after ablation. There was no significant difference between patients with SND and controls in age (p=0.14), left atrial diameter (p=0.43), continuous AF duration (p=0.52). Ablation of the right atrium was performed in 43% of patients with SND compared with 16% of controls (p=0.09). Proportion of female (SND: 57%, controls: 14%; p=0.01), height (1.60±0.1 m vs 1.69±0.08 m, p=0.01), body weight (59±12 kg vs 70±11 kg, p=0.01) significantly differed between patients with SND and controls. Conclusion: Sinus node dysfunction after catheter ablation of persistent AF occurred in 1% of patients. These patients were characterized by female, shorter height and smaller body weight.

Improved current era outcomes in patients with heterotaxy syndromes☆

Patients with heterotaxy syndrome have a myriad of visceral and cardiac malformations historically resulting in significant morbidity and mortality. We sought to assess whether current era management strategies have improved outcomes in patients with visceral heterotaxy. A retrospective review (1994-2008) of our database identified 45 consecutive heterotaxy patients who underwent surgical palliation. There were 29 patients with right atrial isomerism (RAI) and 16 patients with left atrial isomerism (LAI). Functional single ventricle was present in 32 patients. Pulmonary outflow obstruction was present in 29 of the patients. Twenty patients had total anomalous pulmonary venous return (TAPVR), of which 9 were obstructed. An initial neonatal surgical approach was performed in 27 patients. Thirty patients had systemic to pulmonary artery shunt. Mean follow-up was 43.6+/-47 months in RAI and 41.0+/-40.8 months in LAI patients (p=0.4). There were three hospital deaths, all after the first operation, and four interstage deaths (six RAI; one LAI). There were no deaths after cavopulmonary shunt, Kawashima or Fontan operation. A multivariate Cox regression identified greater than moderate atrioventricular valve regurgitation (Hazard Ratio (HR) 17.5, p=0.017) and obstructed TAPVR (HR 17.5, p=0.007) as factors associated with increased RAI mortality. Due to the absence of late mortality in both groups, patient survival at 3 years were 79% in RAI and 94% in LAI patients and remained stable after that (p=0.22). All survivors but one are in NYHA class I or II, without significant cardiovascular related symptoms. LAI patients have a higher incidence of sinus node dysfunction than RAI patients (47% vs 12.5%, p=0.009). Surgical outcomes in heterotaxy patients are improving in the current era. The risk for operative mortality and attrition is highest between the first and second stage palliation procedures. Significant atrioventricular valve regurgitation and obstructed TAPVR remain risk factors for RAI mortality. Survivors are doing well with no activity restrictions, although LAI patients maintain a higher proclivity of sinus node dysfunction.

375: Dual Right Atrial Pacing Improves Paced Heart Rate Response in Orthotopic Heart Transplant Patients

The orthotopic transplanted heart (OHTX) patient may have two sinus nodes, an innervated recipient and a denervated donor, the later being characterized physiologically by autonomic denervation and chronotropic incompetence. Several studies report a high incidence of sinus node dysfunction (SND) following OHTX some requiring pacemakers. Multiple pacemaker techniques are used, with placement of leads in the donor right atrium (AD), donor right ventricle (VD) and recipient right atrial remnant (AR).

Evolving Surgical Strategy for Sinus Venosus Atrial Septal Defect: Effect on Sinus Node Function and Late Venous Obstruction

Our surgical strategy for repair of sinus venosus atrial septal defect has evolved chiefly to avoid sinus node dysfunction. We reviewed our experience with the single-patch, two-patch, and Warden repairs. We identified 54 patients with repair of sinus venosus atrial septal defect from 1990 to 2006. Mean age was 9.5 +/- 12.6 years; median age was 4.2 years. Partial anomalous pulmonary venous connection was found in 52 patients (96%); drainage was to the right atrium in 8, right atrial-superior vena cava (SVC) junction in 17, and directly to the SVC in 27. Techniques were single-patch repair (24), two-patch repair (25), and Warden repair (5). Autologous pericardium was used in all patients. Echocardiogram and electrocardiogram follow-up were available for 48 patients (89%). There were no early or late deaths and no reoperations. No patient had pulmonary vein stenosis. Five patients had SVC stenosis: 2 mild after two-patch repair; 1 moderate and 1 mild after single-patch repair; and 1 severe stenosis after Warden procedure (p = 0.3). The incidence of rhythm change from sinus to low atrial or junctional rhythm was 35% and was significantly greater among patients with two-patch repair (12 of 22, 55%) compared with single-patch repair (5 of 21, 24%), or the Warden repair (0 of 5, p = 0.02). Repair of sinus venosus atrial septal defect with autologous pericardium is associated with a low incidence of late SVC or pulmonary vein stenosis with all techniques. Use of the two-patch technique, however, is associated with a significantly greater incidence of sinus node dysfunction. For the patients with partial anomalous pulmonary venous connection entering the SVC, the Warden procedure avoids interfering with the sinus node and should be used preferentially. The single-patch technique remains the procedure of choice for sinus venosus atrial septal defect with partial anomalous pulmonary venous connection entering the right atrium or right atrium-SVC junction.

Comparison of lateral tunnel and extracardiac conduit Fontan procedure

The purpose of this study was to compare the outcomes of lateral tunnel (LT) and extracardiac conduit (ECC) Fontan procedures at a single institution. From April 1995 to December 2006, 165 Fontan procedures were performed (67 LT, 98 ECC). Pre-, intra- and postoperative variable values were compared between two different techniques. Operative mortality was 5 (3 LT, 2 ECC). Immediate postoperative transpulmonary gradient (LT 8.5+/-ECC 2.5 vs. 6.6+/-2.4 mmHg) and central venous pressure (LT 18.3+/-3.8 vs. ECC 15.6+/-2.4 mmHg) showed significant difference (P<0.001). The LT patients had a higher incidence of sinus node dysfunction in the postoperative period (22.4% vs. ECC 11.2%; P=0.05). Mean follow-up was 74.1+/-31.5 months in LT, and 31.7+/-28.1 months in ECC patients. There was one late death. Actuarial survival at 10 years is 92% for LT, and 89% for ECC patients (P=0.796). The LT and ECC, both, showed comparable early and mid-term outcomes in operative morbidity and mortality, postoperative hemodynamics, survival. Use of ECC for modified Fontan operation reduces the risk of sinus node dysfunction and shows better outcome of immediate postoperative hemodynamics.

Cavo-Atrial Anastomosis Technique for Partial Anomalous Pulmonary Venous Connection to the Superior Vena Cava—The Warden Procedure

Partial anomalous pulmonary venous connection to superior vena cava occurs in about 10 to 15% of all patients with an atrial septal defect. Most commonly one or more pulmonary veins from the right lung connect to the superior vena cava or the right atrium, or both. The usual sinus venosus atrial septal defect occurs above the fossa ovalis immediately beneath the orifice of the superior vena cava, which typically overrides the atrial defect to some extent. Rarely there is no atrial septal defect. 1 Because the clinical manifestationsofbothlesionsaresimilar,itisnotunusualtoencounter anomalous pulmonary veins at the time of operation for presumed uncomplicated secundum atrial septal defect. Idealsurgicalrepairdemandscompleteclosureoftheatrial septal defect and redirection of the anomalous pulmonary veins into the left atrium without pulmonary venous or superior vena cava obstruction and without injury to the sinus node or its blood supply. Normally this is simple when the anomalous pulmonary veins are close to the right atrium. However when they enter further up the superior vena cava, the surgical treatment can be more complex. Various techniques have been described using prosthetic grafts, pericardial patches, or atrial wall flaps to baffle the anomalous pulmonary veins into the left atrium. An alternative atrio-caval anastomosis technique has been utilized at our institution for 42 years to lessen the risk of undesirable complications, particularly sinus node dysfunction.

New Onset Arrhythmias After the Extracardiac Conduit Fontan Operation Compared With the Intraatrial Lateral Tunnel Procedure: Early and Midterm Results

Background Arrhythmias are one of the main causes of postoperative morbidity superseding Fontan operations. Comparative data on the incidence of sinus node dysfunction after the extracardiac Fontan operation (ECFO) and the intraatrial lateral tunnel Fontan operation (LTFO) are very limited and controversial. The aim of this study was to evaluate whether ECFO decreases the risk of postoperative arrhythmias compared with LTFO. Methods Seventy-four consecutive patients received either an LTFO (n = 29, 5 recordings in 1992 to 9 recordings in 1997) or an ECFO (n = 45, 11 recordings in 1995 to 5 recordings in 2001). The rhythm was documented preoperatively and postoperatively with standard electrocardiogram (ECG) recording and ECG monitoring. During follow-up all patients had 2–8 (median 3) standard ECG recordings per year. Additionally 45 patients (65%) had a Holter ECG at least once a year. Results Median follow-up post-ECFO was 4.4 years (1.6–7.2) and post-LTFO it was 7.9 years (5.4–11.1). There were 5 early deaths (3 LTFO, 2 ECFO) and 1 late death (LTFO) (total mortality 8%). Sinus rhythm persisted in 37 ECFO patients (86%) as compared with 13 LTFO patients (50%) ( p < 0.001). The incidence of new onset supraventricular tachyarrhythmias (SVTs) post-ECFO compared with LTFO was lower: 5 patients (11%) versus 11 patients (38%) early postoperatively ( p < 0.001) and none versus 7 patients (27%) during follow-up ( p < 0.001), respectively. Early postoperatively 10 LTFO patients (34%) and another 3 patients during follow-up required permanent pacemaker implantation due to bradyarrhythmias, but none of the ECFO patients required this. Conclusions Our data suggest that ECFO decreases the incidence of postoperative new onset arrhythmias during early and midterm follow-up compared with LTFO.

INVITED COMMENTARY

There is compelling logic to the argument that the extracardiac conduit approach to the Fontan procedure should minimize or avoid arrhythmias. Compared with the lateral tunnel approach, the extracardiac conduit limits atrial suture lines, and avoids exposure of any portion of the atrium to high pressure. At first glance, the report of Nürnberg and colleagues supports this argument: extracardiac conduit patients had lower rates of sinus node dysfunction and supraventricular tachycardia both in-hospital, and during follow-up. This report contains a large amount of information and deserves careful scrutiny. Several points are of interest. Despite the minimization of atrial surgery, patients undergoing an extracardiac conduit Fontan procedure have an incidence of sinus node dysfunction at the time of hospital discharge of approximately 15%. This has been a consistent observation (summarized in their Table 1), being seen in the current report (16%), as well as in reports from the Hospital for Sick Children, Toronto (15%), Children's Hospital of Philadelphia (13%), and Medical University of South Carolina (17%). The reasons for this are unclear, but may include the effects of atrial incisions for associated procedures or fenestration placement, or damage to the sinus node or its blood supply during redissection.

Lateral tunnel versus extracardiac conduit fontan procedure: a concurrent comparison

Background The aim of this study was to compare the outcomes of the lateral tunnel (LT) and extracardiac conduit (ECC) Fontan procedures at a single institution over the same time period. Methods From November 1995 through October 2002, 70 Fontan procedures were performed: 37 LT and 33 ECC. All were fenestrated; 96% were staged with a prior superior cavopulmonary connection. Compared with the ECC patients, the LT patients were younger (2.7 ± 1.1 vs 3.9 ± 2.5 years; p = 0.01), had a higher incidence of hypoplastic left heart syndrome (57% vs 21%; p < 0.01), and a longer aortic cross-clamp time (55 ± 13 vs 26 ± 15 min; p < 0.01). Weight, gender, preoperative cardiac catheterization values, and cardiopulmonary bypass time did not differ between the two groups. Results Operative mortality was 2.8%, 1 patient in each group ( p = 1.0). Over the first 24 hours following operation the mean Fontan pressure, transpulmonary gradient, and common atrial pressure did not differ between LT and ECC patients. The median duration of mechanical ventilation (LT 12 vs ECC 18 hours), intensive care unit stay (LT 2 vs ECC 3 days), chest tube drainage (LT 10 vs ECC 8 days), and hospital stay (LT 11 vs ECC 12 days) did not differ. The ECC patients had a higher incidence of sinus node dysfunction both in the postoperative period (27% vs LT 8%; p = 0.09), and persisting at hospital discharge (10% vs LT 0%; p = 0.02). Mean follow-up was 3.6 ± 1.6 years in LT, and 3.0 ± 2.2 years in ECC patients ( p = 0.2). There was one late death. Actuarial survival at 5 years is 97% for LT, and 91% for ECC patients ( p = 0.4); 96% of patients are in NYHA class I, and 4% in class II, with no difference between groups. Sinus node dysfunction was seen during follow-up in 15% LT vs 28% ECC patients ( p = 0.2). Conclusions The LT and ECC approaches had comparable early and mid-term outcomes, including operative morbidity and mortality, postoperative hemodynamics, resource use, and mid-term survival and functional status. ECC patients had a higher incidence of sinus node dysfunction early after operation.

Arrhythmia after modified total cavopulmonary connection without use of prosthetic material

Background. Although total cavopulmonary connection without use of prosthetic material appeared to be a promising surgical procedure that would retain potential growth of the intraatrial tunnel, midterm incidence of arrhythmia remains unknown. Methods. Twelve patients underwent modified total cavopulmonary connection. A prosthetic material was not used in 5 patients (group F) and was used in 7 patients (group P). A retrospective review of the perioperative electrocardiogram and ambulatory monitoring were performed. Results. All patients revealed regular sinus rhythm before the operation. In the early postoperative period, the incidence of sinus node dysfunction was higher in group F than in group P (80% versus 28.6%). This difference no longer existed by hospital discharge (group F, 20%; group P, 14.3%). In the midterm follow-up period, sinus node dysfunction was detected in 4 patients of group F (80%) and 1 patient of group P (14.3%). Transient tachyarrhythmia was detected in 1 patient of group F and 3 patients of group P. Conclusions. Modified total cavopulmonary connection without use of prosthetic material affected unfavorably the sinus node in the early and midterm postoperative period.