Follow-Up of a Prospective Surgical Strategy to Prevent Intra-Atrial Reentrant Tachycardia After the Fontan Operation

Law, Ian H.; Alam, Osman; Bove, Edward L.; Bradley, David J.; Yu, Sunkyung; Dick, Macdonald

doi:10.1161/circep.116.004478

Cited by 3 publications

(1 citation statement)

References 39 publications

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“…On to this most recent, carefully designed, and constructed clinical study of this approach, an article presented in this issue by Law et al 9 Given that periannular and scar-based macroreentrant circuits are common even in Fontan patients, they hypothesized that simple surgical modification of the atriotomy in clinical practice might also reduce the prevalence of IART, assessed many years later. Specifically, this involves attachment of the atriotomy to a nonconducting barrier, such as the right atrioventricular valve annulus.…”

Section: See Article By Law Et Almentioning

confidence: 99%

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Triedman

2016

Circ: Arrhythmia and Electrophysiology

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A trial arrhythmias have for decades been recognized as a principal late complication of the Fontan procedure. A specific connection between the 2 was recognized soon after the procedure emerged as a standard clinical pathway for patients with single ventricle physiology. Intra-atrial reentrant tachycardia (IART) is a major cause of morbidity in the form of recurring symptoms and need for medical intervention in these patients. 1 Early on, risk factors for future IART were identified, most notably the occurrence of atrial arrhythmia in the perioperative period. 2 The relationships between organized atrial tachycardias and comorbidities such as thromboembolism, heart failure, and mortality have been investigated and are now well established. 3 These observational associations were established through retrospective studies, which could not allow for attribution of causality. Despite this weakness of this type of clinical evidence, IART has been clearly identified in multiple concordant studies as one of the bad actors predictive of poor long-term outcome in patients undergoing the Fontan procedure. See Article by Law et alThis association of arrhythmia with a specific congenital heart operation has been vigorously pursued by surgeons and electrophysiologists as a potentially modifiable factor, which could perhaps be exploited in an attempt to avoid late occurrence of IART. There is a well-known relationship between atrial myocardial injury and atrial flutter, and experimental surgical models that mimic the atrial manipulations used by congenital heart surgeons are reliable and potent promoters of reentrant tachycardia. This suggests that carefully designed changes in how the atrial myocardium is managed at the time of Fontan surgery could perhaps preempt and favorably alter the observed arrhythmogenic process.One such approach proposed as means by which arrhythmia prophylaxis (along with other theoretical hemodynamic benefits) could be achieved is to exclude the right atrium altogether, by using an extracardiac conduit to complete the connection between inferior and superior vena cava. This is in theory a no touch technique that both minimizes surgical intervention to the right atrium (although an atriotomy scar does exist in most cases where the lateral wall of the atrium has been excised) and leaves all of the atrial myocardium at lower, pulmonary venous pressures. Postoperative atrial arrhythmias are in fact seen in this group at low prevalence during the first decade of follow-up. However, the prevalence of IART also seems to be lower in other forms of Fontan, such as the lateral tunnel approach. It is fair to say that the specific, beneficial effect of surgical strategy in Fontan completion, whether lateral tunnel or extracardiac conduit, has been difficult to untangle from what appears to be a general trend to decreasing prevalence of sustained atrial arrhythmias in all recent Fontan patients. [4][5][6] We understood some time ago of the specific importance of the atriotomy as a promoter of IART in Fontans a...

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Section: See Article By Law Et Almentioning

confidence: 99%

Moving the Goalposts

Triedman

2016

Circ: Arrhythmia and Electrophysiology

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Late development of intra-atrial reentrant tachycardia in lateral tunnel Fontan patients and the preventive role of prophylactic cryoablation

Ryu,

Song,

Lee

et al. 2024

The Journal of Thoracic and Cardiovascular Surgery

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Long-term results of atrial maze surgery in patients with congenital heart disease

2019

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Aims Recurrent atrial tachycardia is common after repair of many types of congenital heart disease, and surgical ablation with a maze procedure represents a potential treatment strategy. The objective of this study is to report a single-centre 19 years’ experience with maze surgery in congenital heart patients. Methods and results Patients undergoing maze procedure concomitantly with cardiac surgical procedures were retrospectively analysed. The maze procedure was classified as therapeutic if the patient demonstrated preoperative atrial arrhythmias, or as prophylactic if done because the patient was considered high risk for post-operative arrhythmias. Acute outcomes and longer-term freedom from atrial arrhythmias were analysed. Maze surgery was performed in 166 patients: 137 in the therapeutic group, and 29 in the prophylactic group. The most common congenital heart lesion was single ventricle for the therapeutic group (27%) and Ebstein’s anomaly for the prophylactic group (76%). Surgery consisted of a right atrial maze in 63%, left atrial maze in 4%, and bilateral maze in 33%. There were no direct complications or mortality related to the maze procedure itself. For the therapeutic group, freedom from arrhythmias was 82% and 67% at 1 and 5 years post-maze. Younger age at the time of surgery correlated with a lower long-term recurrence risk. Conclusion Maze procedure at the time of an elective anatomic surgery is reasonably effective to prevent and treat atrial arrhythmias in patients with congenital heart disease at short- and mid-term, with low morbidity and mortality.

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Follow-Up of a Prospective Surgical Strategy to Prevent Intra-Atrial Reentrant Tachycardia After the Fontan Operation

Cited by 3 publications

References 39 publications

Moving the Goalposts

Moving the Goalposts

Late development of intra-atrial reentrant tachycardia in lateral tunnel Fontan patients and the preventive role of prophylactic cryoablation

Long-term results of atrial maze surgery in patients with congenital heart disease

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