Surgical management of posteroseptal accessory atrioventricular pathways

From October 1988 through January 1991, 22 consecutive patients with Wolff-Parkinson-White syndrome underwent surgical ablation of symptomatic accessory posteroseptal atrioventricular pathways at our institution. As our experience with posteroseptal tracts accumulated, we found that surgical technique was logically dictated by the presence of free wall tracts and the exact location of the posteroseptal tract. Accordingly, we developed an operative approach that involves the selective use of endocardial, epicardial, and cryoablation techniques depending on the anatomic location of accessory tracts. This selective approach allows one to exploit the advantages of each technique while minimizing associated disadvantages. There were 14 men and 8 women with an average age of 25 years (range, 19 to 39 years). All patients had symptomatic tachyarrhythmias caused by accessory atrioventricular pathway(s). Most required several antiarrhythmic medications and 17 (77%) had poor arrhythmia control despite maximal medical therapy. Twelve patients had two accessory pathways and 3 also had dual atrioventricular nodal pathways. There were no early or late deaths. In 2 patients, a delta wave associated with a free wall tract reappeared 3 to 5 days after the initial operation, necessitating a second operation which successfully eliminated the accessory tract. All posteroseptal tracts were successfully eliminated during the initial operation. All patients were relieved of symptoms and are now free of medical therapy. Each patient has undergone a postoperative electrophysiologic study which confirms the absence of posteroseptal accessory conduction. The selective approach has been totally successful in our hands and should prove useful to those interested in optimizing the efficiency of surgical procedures for Wolff-Parkinson-White syndrome.