The surgical anatomy of Kent bundles based on electrophysiological mapping and surgical exploration

The development of the procedure for interruption of a Kent bundle for the correction of the tachyarrhythmias associated with the Wolff-Parkinson-White syndrome has been hampered by the lack of anatomic descriptions of the pathways. Only 21 descriptions are given in enough detail for guidance to the surgeon. Our experience with our first 100 patients operated upon for serious dysrhythmias associated with Kent bundles has supplemented this information. In our first 40 patients the Kent was divided in 22 of 39, one having elective and four having forced interruption of the His bundle, with success in 28. In the next 60 the Kent was divided in 52 of 59 attempts, one had elective and three had forced His bundle interruption, and the success rate was 56 of 60 patients. This increased success occurred because we learned the following: (1) The anomalous pathways are best approached through the atrium and can be for out in the fat, even subepicardial in the coronary sulcus or adjacent to the anulus. (2) Interruption should be started with an incision made just above the anulus fibrosus. (3) Posterior septal pathways can be adjacent to the His bundle or in the septum from this point posteriorly to the crux. (4) Anterior septal pathways can be divided and the His bundle protected. The details for the approach to the right and left free wall, posterior septal, and anterior septal pathways will be given. The approach to all pathways is now safe enough to allow the surgeon to offer this operation to patients with life-threatening tachyarrhythmias as well as the ones with rhythm disturbances that are either burdensome or impossible to treat medically.