Optimal surgical ablation of atrial tachyarrhythmias during correction of Ebstein anomaly

Ebstein anomaly (EA) is commonly associated with atrial flutter or fibrillation (AFl/F), which adversely affects outcome. Surgical ablation of AFl/F during surgery for EA has been shown to be effective, but the optimal lesion set remains unknown.

Between 1995 and 2010, 86 patients had corrective surgery for EA and concomitant maze procedure for associated AFl/F. Median age at operation was 40 years (range, 1 to 72 years), and 49 patients (60%) were male. Preoperative AFl/F was paroxysmal in 43 patients (50%). All patients who had diagnosis of or treatment for accessory pathways and reentrant tachycardia were excluded from this analysis.

All patients underwent tricuspid valve surgery for EA and concomitant maze procedure, including right-sided maze (RSM) in 62 patients (72%) and biatrial maze (BAM) in 24 patients (28%). Early mortality occurred in 3 patients (3.5%). During median follow-up of 52 months (range, 3 months to 17 years), overall freedom from AFl/F without antiarrhythmic medications was 79% (RSM, 80% versus BAM, 76%; p = 0.97). Although there was no difference in rhythm outcome between RSM and BAM for patients with paroxysmal AFl/F (p = 0.08), there was a trend toward higher freedom from AF without antiarrhythmic medications in patients with persistent AFl/F for BAM (86%) versus RSM (71%; p = 0.053). Overall, there were no late strokes, and 84% were free from sodium warfarin anticoagulation.

Overall, surgical ablation of preoperative AFl/F is effective in patients undergoing surgery for EA. Although rhythm outcome of RSM and BAM did not differ in patients with preoperative paroxysmal AFl/F, those with persistent or permanent AFl/F may benefit from a biatrial lesion set.