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Modifications to the cavopulmonary anastomosis do not eliminate early sinus node dysfunction
M I Cohen1, N D Bridges, J W Gaynor
1Divisions of Cardiology and Cardiothoracic Surgery and The Departments of Pediatrics and Surgery, The Children's Hospital of Philadelphia and The University of Pennsylvania School of Medicine, Philadelphia, PA, USA. mi@email.chop.edu
Insights
Surgery near the sinus node does not increase the risk of sinus node dysfunction after Fontan procedures. Patient anatomy and surgeon preference should guide surgical decisions, not concerns about early sinus node dysfunction.
Area of Science:
- Pediatric Cardiology
- Congenital Heart Disease Surgery
- Electrophysiology
Background:
- Sinus node dysfunction is a potential complication following Fontan-type procedures.
- Certain surgical techniques theoretically place the sinus node at higher risk.
Purpose of the Study:
- To compare the incidence of sinus node dysfunction between surgical approaches that do and do not directly involve the sinus node.
- To inform surgical decision-making regarding cavopulmonary anastomosis selection.
Main Methods:
- Prospective cohort study of 130 patients undergoing bidirectional Glenn, hemi-Fontan, extracardiac conduit, or lateral tunnel Fontan procedures.
- Sinus node dysfunction defined by heart rate or rhythm abnormalities on ECG and ambulatory monitoring.
- Data collected from January 1996 to December 1999.
Main Results:
- Early sinus node dysfunction was higher after hemi-Fontan (36%) vs. bidirectional Glenn (9.8%), but this difference resolved by discharge.
- No significant difference in early sinus node dysfunction between extracardiac conduit (13%) and lateral tunnel (13%) Fontan procedures.
- No predictive variables for sinus node dysfunction were identified.
Conclusions:
- Surgical proximity to the sinus node does not impact the development of early sinus node dysfunction.
- Surgical strategy should prioritize patient anatomy and surgeon expertise over concerns regarding sinus node dysfunction.
Objective:
To determine whether operations that theoretically jeopardize the sinus node (hemi-Fontan and/or lateral tunnel Fontan procedures) are associated with a greater risk of sinus node dysfunction than those that theoretically spare the sinus node (bidirectional Glenn and/or extracardiac conduit).
Methods:
Between January 1, 1996, and December 31, 1999, a prospective cohort study was conducted evaluating the incidence of sinus node dysfunction in patients undergoing a bidirectional Glenn or hemi-Fontan procedure and those in whom the Fontan repair was completed with either an extracardiac conduit or a lateral tunnel. Sinus node dysfunction was defined (1) as a heart rate more than 2 SD below age-adjusted norms or (2) as a predominant junctional rhythm and/or a sinus pause of more than 3 seconds as determined by the resting electrocardiogram and/or ambulatory monitoring at hospital discharge.
Results:
Fifty-one patients had a bidirectional Glenn shunt (mean age 7.8 +/- 5.1 months) and 79 a hemi-Fontan procedure (mean age 6.9 +/- 2.8 months). The incidence of sinus node dysfunction on postoperative day 1 was significantly higher after the hemi-Fontan (36%) than after the bidirectional Glenn shunt (9.8%); however, by hospital discharge this difference was no longer apparent (hemi-Fontan [8%]; bidirectional Glenn [6%]; P = not significant). No difference in early sinus node dysfunction was discernible after the extracardiac conduit (4/30 [13%]) compared with the lateral tunnel Fontan procedure (6/46 [13%]) (P = not significant). No diagnostic or perioperative variables were predictive of sinus node dysfunction.
Conclusions:
Avoidance of surgery near the sinus node has no discernible effect on the development of early sinus node dysfunction. Thus, concerns about early sinus node dysfunction should not override patient anatomy or surgeon preference as determinants of which cavopulmonary anastomosis to perform.