Ann Thorac Surg 1997;64:541-542
© 1997 The Society of Thoracic Surgeons
Case Reports
Right Atrial Separation for Chronic Atrial Fibrillation With Atrial Septal Defects
Taijiro Sueda, MD,
Kenji Okada, MD,
Shinnji Hirai, MD,
Kazumasa Orihashi, MD,
Hideyuki Nagata, MD,
Yuichiro Matsuura, MD
First Department of Surgery, Hiroshima University School of Medicine, Hiroshima, Japan
Accepted for publication March 21, 1997.
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Abstract
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A right atrial separation procedure was performed for the ablation of atrial fibrillation during the concomitant repair of an atrial septal defect. This procedure consisted of a Y-shaped incision in the right atrium, followed by cryoablation of the tricuspid annulus and the atrial septum without any procedures performed on the left atrium. This is a simple and effective method for the elimination of chronic atrial fibrillation associated with atrial septal defects in adults.
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Introduction
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Atrial fibrillation (AF) is a common arrhythmia found with atrial septal defects (ASDs) in adults [1–3]. The incidence of AF increases with the patient's age. However, repair of the ASD rarely eliminates the chronic AF once it has persisted for more than 1 year [4, 5]. We have devised a simple procedure for ablating the chronic AF associated with ASD, designated as the right atrial separation procedure. The procedure divides the right atrium into three parts to reduce the right atrial mass, and contributes to the elimination of chronic AF. Here we report a surgical case of an ASD with a long history of chronic AF corrected by this procedure.
A 53-year-old man had a heart murmur since childhood. For the previous 10 years, he had exertional dyspnea and palpitation. Electrocardiography showed permanent AF and an incomplete right bundle-branch block. Digoxin and disopyramide were not efficacious against this chronic AF. The echocardiogram showed a large ASD with moderate tricuspid valve regurgitation. Cardiac catheterization confirmed a large septal defect, showed that the ratio of pulmonary flow to systemic flow was 2.0, and revealed a pulmonary arterial systolic pressure of 35 mm Hg.
The operation was performed through a median sternotomy. Cardiopulmonary bypass was instituted through cannulation of the aorta and both venae cavae. The body was kept warm at 34°C. After the aorta was clamped, cold blood cardioplegia was infused for myocardial protection. The right atrial separation procedure was performed with a Y-shaped incision in the right atrium. A longitudinal incision was made 3 cm lateral and parallel to the sulcus terminalis, and was curved to 3 cm (upper incision) and 1 cm (lower incision) distant from the tricuspid annulus. A horizontal incision toward the sulcus terminalis was then added. The sinoatrial node and its artery were protected from injury. Cryoablation at -60°C for 2 minutes was delivered to the atrial septum between the sulcus terminalis and the defect, and to the atrial tissues between the upper incision margin and the tricuspid annulus to complete the procedure (Fig 1
). After this procedure, the right atrium was electrically divided into three parts. One part consisted of the right atrial free wall, and the other two were the upper and the lower atrial septum. These areas were electrically connected as shown in Figure 1. Through the right atriotomy, the atrial septal defect was closed and the tricuspid valve regurgitation was repaired by a DeVega procedure. After release of the aortic cross-clamp, air was evacuated through the aortic root. The right atriotomy was then closed. The cardiac cross-clamp time was 36 minutes, and the cardiopulmonary bypass time was 73 minutes.
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Fig 1. . Schema of the right atrial separation procedure. A longtudinal incision was made lateral and parallel to the sulcus terminalis, extended to the tricuspid annulus, and a horizontal incision was also made from the center of the londitudinal incision to the atrial septum. Cryolesions (black line) were created in areas of the tricuspid annulus and the atrial septum. Arrows indicate the direction of electrical conduction from the sinoatrial node. (ASD = atrial septal defect; CS = coronary sinus; IVC = inferior vena cava; RA = right atrium; SN = sinus node; SVC = superior vena cava; TV = tricuspid valve.)
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A sinus rhythm recovered spontaneously, and a regular sinus rhythm was sustained during the hospital stay. Digoxin and disopyramide were prescribed as prophylaxis against atrial tachycardia and premature atrial beats. In the electrophysiologic studies, atrial activations in the divided right atrium were found to follow the sinus impulses synchronously (Fig 2). A Doppler echocardiographic study revealed that the contractility of both atria had recovered after the operation. The sinus node recovery time was 1,400 milliseconds, and the sinoatrial conduction time was 145 milliseconds at rest. The atrial fibrillation did not recur for 8 months after the operation.
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Fig 2. . Electrocardiogram after the operation. The atrial contractive wave is found in lead V1. The atrial activation waves of the right atrium consist of a large negative wave in an area near the sinus node (1), a biphasic wave in the right atrial free wall (2), and a biphasic wave in the lower margin of the sulcus terminalis (3). These findings demonstrate electrical conduction from the sinus node to the areas divided by this procedure.
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Comment
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Chronic AF associated with ASD often persists despite proper repair of the cardiac defect [1–5]. This warrants surgical correction of the AF itself because many deleterious complications secondary to AF have been documented. The maze procedure has been reported for the surgical ablation of AF in patients with ASD, and has proved to be effective in conversion to a sinus rhythm [6]. The idea behind the original maze operation was to divide all possible areas for macroreentry, and to restore atrial contractility [7, 8]. However, the maze procedure is a meticulous and time-consuming operation and takes much more operative time than this procedure. Our previous electrophysiologic study in patients with isolated mitral valve disease and chronic AF showed that the distended left atrium had a shorter refractory period than the right atrium, and a surgical procedure on the posterior wall of the left atrium only was adequate to eliminate the AF associated with isolated mitral valve disease [9]. We postulated that the dilated atrium has a shorter refractory period, and thus acts as a driver for the chronic AF. In cases of isolated mitral valve disease, the left atrium is always larger than the right atrium [10]. In contrast, the right atrium is typically larger than the left atrium in cases of ASD. This patient also showed a larger diameter of the right atrium than that of the left. But large left atrium can exist even in cases of ASD, and it is questionable to perform this right atrial procedure in cases of left atrial enlargement. Although this was only a single case, the right atrial separation procedure seems efficacious for eliminating the chronic AF associated with ASD and right atrial enlargement.
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Footnotes
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Address reprint requests to Dr Sueda, First Department of Surgery, Hiroshima University School of Medicine, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734, Japan.
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References
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- Tikoff G, Schmidt AM, Hecht HH. Atrial fibrillation in atrial septal defect. Arch Intern Med 1968;121:401–5.
- Murphy JG, Gersh BJ, McGoon MD, et al. Long-term outcome after surgical repair of isolated atrial septal defect. Follow-up at 27 to 32 years. N Engl J Med 1990;323:1645–50.[Abstract]
- Bonchek LI, Burlingame MW, Worley SJ, Vazales BE, Lundy EF. Cox/maze procedure for atrial septal defect with atrial fibrillation: management strategies. Ann Thorac Surg 1993;55:607–10.[Abstract]
- Cox JL, Canavan TE, Schuessler RB, et al. The surgical treatment of atrial fibrillation. II. Intraoperative electrophysiologic mapping and description of the electrophysiologic basis of atrial flutter and atrial fibrillation. J Thorac Cardiovasc Surg 1991;101:406–26.[Abstract]
- Cox JL, Schuessler RB, D'Agostino HJ, et al. The surgical treatment of atrial fibrillation. III. Development of a definitive surgical procedure. J Thorac Cardiovasc Surg 1991;101:569–83.[Abstract]
- Sueda T, Nagata H, Shikata H, et al. Simple left atrial procedure for chronic atrial fibrillation associated with mitral valve disease. Ann Thorac Surg 1996;62:1796–800.[Abstract/Free Full Text]
- Sueda T, Nagata H, Orihashi K, et al. Efficacy of a simple left atrial procedure for chronic atrial fibrillation in mitral valve operations. Ann Thorac Surg 1997;63:1070–5.[Abstract/Free Full Text]
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Abstract
Introduction
