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P wave signal averaged electrocardiography in patients undergoing the Fontan operation
Noboru Inamura1, Tohru Matsushita, Masatake Fukunami
1Department of Developmental Medicine (Pediatrics), Osaka University Graduate School of Medicine, Osaka.
Insights
The Fontan operation can lead to atrial degeneration and arrhythmias, particularly after atriopulmonary connections. Early detection of these risks is crucial for managing patients post-Fontan procedure.
Area of Science:
- Cardiology
- Pediatric Cardiology
- Cardiac Surgery
Background:
- Supraventricular arrhythmias are common and fatal complications following the Fontan operation.
- Atrial degeneration is a suspected underlying cause of these arrhythmias.
Purpose of the Study:
- To evaluate atrial degeneration using P wave signal-averaged electrocardiography in Fontan patients.
- To identify factors contributing to atrial arrhythmia development post-Fontan.
Main Methods:
- P wave triggered signal-averaged electrocardiography was performed on 14 Fontan patients (5 atriopulmonary, 9 total cavopulmonary) and 15 controls.
- Analysis included filtered P wave duration/area and frequency domain signal magnitudes (M20, M30).
- Hemodynamic data and right atrial volume were compared between groups.
Main Results:
- Patients with atriopulmonary connections showed significantly increased P wave duration, area, M20, and M30 compared to total cavopulmonary and control groups.
- Right atrial volume was significantly larger in the atriopulmonary connection group versus the total cavopulmonary group.
- M20 was elevated in the total cavopulmonary group compared to controls.
Conclusions:
- The Fontan operation, especially atriopulmonary connections, creates a substrate for atrial arrhythmias due to myocardial degeneration and fibrosis.
- Enlarged right atria likely contribute to the arrhythmogenic substrate.
- Even total cavopulmonary connections carry a risk for late atrial arrhythmias.
Objectives:
Supraventricular arrhythmias are one of the most common and fatal sequelae of the Fontan operation. P wave triggered signal averaged electrocardiography was performed in patients undergoing the Fontan operation to evaluate the presence of atrial degeneration, and to clarify which factors affected the development of atrial arrhythmias.
Methods:
P wave triggered signal averaged electrocardiography was recorded in 14 patients after the Fontan-type operation (conventional atriopulmonary connection in 5 and total cavopulmonary connection in 9) and 15 healthy controls. The duration and area of the filtered P wave, and the signal magnitudes (M20, M30) at 20 Hz and 30 Hz obtained from the frequency domain analysis of the P wave (M20, M30) were evaluated and compared with the hemodynamic data.
Results:
The duration and area of the filtered P wave, M20 and M30 in patients after atriopulmonary connection were significantly greater than in those after total cavopulmonary connection and the control subjects (p < 0.05). M20 was significantly greater in patients after total cavopulmonary connection than in the control subjects. Right atrial volume in patients after atriopulmonary connection was significantly (p < 0.001) larger than in patients after total cavopulmonary connection (p < 0.05). There were no significant differences in other indices including atrial pressure between the two groups.
Conclusions:
Our results suggest that the substrate for atrial arrhythmias such as atrial myocardial degeneration and fibrosis is frequently present in patients after the Fontan operation, especially after atriopulmonary connection. Thus, the enlarged right atrium may be involved in the presence of a substrate for atrial arrhythmias. The developmental risk for late atrial arrhythmias seems to be present even in patients after total cavopulmonary connection.