Anatomically guided surgery to the AV node *1AV nodal skeletonization: experience in 46 patients with AV nodal reentrant tachycardia

Abstract

We report our combined experience with operative therapy for atrioventricular nodal tachycardia using an anatomically guided procedure. The operative rationale was to dissect the AV node with the intent of modifying perinodal tissues (skeletonization). The anterior septal and posterior septal regions were initially approached epicardially to facilitate endocardial dissection. Under normothermic cardiopulmonary bypass, the right atrial septum was mobilized and the intermediate AV node was exposed anterior to the tendon of Todaro. Ablation of concomitant accessory pathways was done prior to AV nodal skeletonization. Forty-six patients aged 9-71 years (mean 36) were operated upon. Five patients had accessory pathways in addition to AV nodal reentry. At electro-physiological study prior to discharge, no patient had an AV block although anterograde and retrograde Wenckebach cycle lengths were significantly prolonged. Ten patients had a retrograde AV block. The 46 patients were free of arrhythmia and not taking antiarrhythmic medication after a follow-up of 1-45 months (mean 17). Three patients had a recurrence of the tachycardia 10 days, 2 months and 7 months post-operatively, respectively. All patients had a subsequently successful reoperation.

The History of AV Nodal Reentry

“…The earliest attempts at nonpharmacologic cure of AVNRT involved surgical dissection in Koch's triangle. This technique was first introduced by Ross et al, 33 and the results were confirmed by a number of surgical groups 34–36 . Not only did the surgical reports pioneer non‐pharmacologic therapy but an impressive array of physiologic data was discovered.…”

“…This technique was first introduced by Ross et al, 33 and the results were confirmed by a number of surgical groups. [34][35][36] Not only did the surgical reports pioneer nonpharmacologic therapy but an impressive array of physiologic data was discovered. For example, high resolution mapping of Koch's triangle showed two distinct types of atrionodal connections in patients with "typical" slow-fast AVNRT.…”