The Annals of Thoracic Surgery, Vol 43, 579-584, Copyright © 1987 by The Society of Thoracic Surgeons
Technical considerations in the surgical approach to multiple accessory pathways in the Wolff-Parkinson-White syndrome
JG Selle, WC Sealy, JJ Gallagher, JM Fedor, RH Svenson and SH Zimmern
Surgical techniques for the approach to and division of atrioventricular
accessory pathways have been designed and perfected during the past 18
years. The standard method of exposure of a single left free wall accessory
pathway is by a left atriotomy. All other single accessory pathways are
exposed through a right atriotomy. Up to twenty percent of patients with
Wolff-Parkinson-White (WPW) syndrome harbor multiple atrioventricular
accessory pathways. In this subgroup, classic operative techniques,
especially the methods of approach, must be combined or modified depending
on the specific locations of the accessory pathways encountered. Eighteen
of 90 patients operated on for WPW syndrome at Charlotte Memorial Hospital
from August, 1983, through September, 1986, had multiple accessory
pathways. Thirty-eight of thirty-nine pathways were successfully divided.
One posterior septal accessory pathway reappeared 2 months postoperatively
and was catheter ablated. The most frequent combination of atrioventricular
accessory pathways included a right free wall and a posterior septal
accessory pathway (10 patients). This combination is approached by a right
atriotomy. The posterior septal space dissection is extended onto the right
free wall area. Technically the most difficult combination includes a left
free wall and a posterior septal accessory pathway (3 patients in the
present series). Our preferred approach is begun with a right atriotomy for
the posterior septal space dissection, followed by an atrial septotomy to
expose the left free wall area. There are other methods, however, that may
be advantageous depending on the exact locations of the accessory pathways
encountered.
