Ann Thorac Surg 1997;64:1389-1395
© 1997 The Society of Thoracic Surgeons
Original Articles: Cardiovascular
Prevention of Unbalanced Lung Perfusion and Atrial Arrhythmias After the Lateral Tunnel Operation
Monica C. Robotin, FRACS,
Alain Serraf, MD,
Lucille Houyel, MD,
Jerome Petit, MD,
François Lacour-Gayet, MD,
Jacqueline Bruniaux, MD,
Claude Planche, MD
Department of Pediatric Cardiac Surgery, Marie-Lannelongue Hospital, Le Plessis-Robinson, France
Accepted for publication May 29, 1997.
 |
Abstract
|
|---|
Background. The lateral tunnel operation has become increasingly popular with pediatric cardiac surgeons, as it is technically reproducible, is relatively easy to perform, and can be used in a variety of patients with single-ventricle physiology. The main drawbacks of the original operation are uneven blood flow distribution to the lungs and increasing incidence of supraventricular arrhythmias over time.
Methods. In 1988, we modified this technique by avoiding narrowing of the tunnel at the superior vena cava–atrial junction, avoiding incorporation of the crista terminalis in the baffle suture line, and minimizing damage to the sinoatrial node. Between 1988 and 1995, 19 patients underwent this operation at Marie-Lannelongue Hospital in Paris.
Results. There was one early death and no late deaths. At a mean follow-up of 5.2 years, all survivors are in New York Heart Association class I. Early atrial flutter, related to atrial scarring secondary to multiple previous surgical procedures, developed in 1 patient, and late atrial flutter developed in 1 patient who had a previous Blalock-Hanlon atrial septectomy. All patients are currently in sinus rhythm. Atrial flutter did not occur in 17 patients who had had no previous atrial wall surgical procedure.
Conclusions. We believe that the good long-term clinical results are directly attributable to our modifications, which ensure optimal hemodynamics and absence of rhythm disturbances. All patients who had not previously undergone operation on the atrial wall were free from supraventricular tachyarrhythmias at a mean follow-up of 5.2 years. This is a consequence of protecting the sinus node, crista terminalis, and Bachmann's bundle.
|
Introduction
|
|---|
In 1968, Fontan performed an atriopulmonary anastomosis in a patient with tricuspid atresia, thus opening the way for successful palliation of many complex cardiac anomalies [1]. Numerous surgeons have contributed technical modifications to the original operation to make it simpler, to make it more reproducible, and to produce better hemodynamics. In 1987, Puga and associates [2] reported a technique that diverted the superior vena cava (SVC) return into both pulmonary arteries and the inferior vena cava (IVC) return, through a tunnel constructed inside the right atrium, to the cardiac end of the SVC, itself anastomosed to the lower border of the pulmonary confluence. This technique is applicable to many complex cardiac anatomies and became known as the lateral tunnel operation. In 1988, de Leval and co-workers [3] presented a very elegant experimental model of this operation and proved that maximal forward flow was achievable through a lateral tunnel of uniform caliber. In most cases, the cardiac end of the SVC has a smaller diameter than does the IVC, and in the interest of laminar flow, it has to be enlarged (Fig 1
). Puga [4] recommended enlargement in a posteromedial direction, whereas de Leval and colleagues [3] advocated enlarging the SVC anteromedially. In the Norwood method, the enlargement runs in an anteromedial direction, but this incision is extended across Bachmann's bundle (see Fig 1).
View larger version (93K):
[in this window]
[in a new window]
|
Fig 1. . Four methods of enlargement of superior vena cava–atrial junction during lateral tunnel operation. (AO = aorta; IAB = interatrial bundle; LAA = left atrial appendage; PV = pulmonary vein; RAA = right atrial appendage; SVC = superior vena cava.)
|
|
Our group [5] started using the lateral tunnel operation in 1988 but modified the way the baffle was sutured inside the right atrium and enlarged the SVC–right atrial junction posterolaterally. The reasons for these modifications were to maintain laminar flow, optimize flow distribution between the lungs, and avoid potential rhythm disturbances caused by incisions in the vicinity of the sinus node. The technique was initially reserved for pathologic entities for which a direct atriopulmonary connection was considered suboptimal.
Because the mean duration of follow-up now exceeds 5 years, by which time in most series rhythm disturbances start to become more and more frequent, we decided to review the cases of our patients, critically assess the results, and see whether it would be appropriate to liberalize the surgical indications to other patient groups [6, 7].
|
Material and Methods
|
|---|
Patient Population
Between November 1988 and March 1995, 19 patients underwent a lateral tunnel operation with posterolateral enlargement of the superior anastomosis at the pediatric cardiac surgery unit of Marie-Lannelongue Hospital in Paris. The patient data are summarized in Table 1. There were 9 girls and 10 boys ranging in age between 1 year and 12.1 years (mean age, 4.04 years). Their weight ranged between 8.7 and 31.5 kg (mean weight, 14.1 kg).
The cardiac pathology was tricuspid atresia with normally related great vessels in 11 patients, double-inlet left ventricle in 3, mitral atresia in 2, atrioventricular septal defect with hypoplasia of one ventricle in 2, and pulmonary atresia with intact ventricular septum in 1 patient. Associated anomalies included dextrotransposition of the great arteries in 3 patients and coarctation of the aorta, parachute mitral valve, mitral regurgitation, and aortic insufficiency in 1 patient each. All but 1 patient had had one or more previous operative procedures. Fourteen patients had 16 systemic–pulmonary artery shunts, 5 patients had had pulmonary artery banding, 1 patient had had a Blalock-Hanlon atrial septectomy, and 1 had had infundibular resection and reestablishment of right ventricle–pulmonary artery continuity to try to promote right ventricular growth. A bidirectional Glenn anastomosis was used as a staging procedure in only 1 patient.
All patients had preoperative cardiac catheterization.
Surgical Procedure
The operation is performed through a midline sternotomy. The SVC is cannulated at the level of the innominate vein and the IVC, through the body of the right atrium. Prior to commencement of bypass, the systemic–pulmonary shunts are dissected, and the SVC and pulmonary arteries are mobilized. The shunts are ligated on commencement of cardiopulmonary bypass, which is carried out with moderate hypothermia at 29°C. The intracardiac repair is performed with the heart arrested with cardioplegia infused into the aortic root and the use of topical cooling. A limited right atriotomy, parallel to the atrioventricular groove allows inspection of the anatomy and IVC tunnelization. If small, the atrial septal defect is enlarged within the confines of the fossa ovalis.
The tunnel is created with the use of a Gore-Tex patch (W.L. Gore & Associates, Flagstaff, AZ) cut in the shape of a half cylinder. Suturing commences on the interatrial septum posterior to the fossa ovalis, descends toward the IVC with the coronary sinus to the left side, and then follows the IVC to the free wall of the right atrium. Superiorly, the patch curves at a distance from the SVC orifice because it is sewn outside the ridge formed by the crista terminalis, and anteriorly it descends parallel and anterior to the crista to meet the previous suture (Fig 2). This avoids the narrowing of the tunnel at the midatrial level, which can occur opposite the fossa ovalis.
View larger version (50K):
[in this window]
[in a new window]
|
Fig 2. . Modified lateral tunnel operation. The suture line commences posterior to the fossa ovalis and then follows the inferior vena cava (IVC) to the free wall of the right atrium, where it ascends anterior to the crista terminalis (CT) describing a large arc around the superior vena cava (SVC), and descends on the interatrial septum to complete the baffle. (ASD = atrial septal defect; CS = coronary sinus; P = polytetrafluoroethylene patch; TV = tricuspid valve.)
|
|
The SVC is transected 5 mm above its cardiac end, and an end-to-side anastomosis is performed between the cephalic end of the SVC and the superior aspect of the right pulmonary artery. The cardiac end of the SVC is then enlarged posterolaterally to match the internal diameter of the IVC (Fig 3). If an anastomosis to the lower border of the right pulmonary artery is feasible without any tension, it is performed directly, but in most cases, we found it necessary to use a teardrop-shaped patch of Gore-Tex to ensure a wide anastomosis. We always tried to spare the sinus node artery, but this was not possible in 2 patients in whom the artery passed behind the SVC–right atrial junction.
View larger version (20K):
[in this window]
[in a new window]
|
Fig 3. . The cardiac end of the transected superior vena cava (SVC) is enlarged posterolaterally, and a gusset of polytetrafluoroethylene may be used to ensure a wide anastomosis. (RPA = right pulmonary artery; SAN = sinoatrial node.)
|
|
Additional procedures at the Fontan operation were required in 6 patients. Three needed branch pulmonary artery reconstruction, 1 had patching of the posterior interatrial septum after a Blalock-Hanlon atrial septectomy, and 1 had patch closure of the tricuspid valve. In 1 patient, an aortoplasty was performed to reduce the size of the ascending aorta. The interatrial baffle was fenestrated in 2 patients. One of them had mitral regurgitation, and in the other, there was still a fear of elevated pulmonary vascular resistance despite encouraging findings at cardiac catheterization.
|
Results
|
|---|
There were no intraoperative deaths. One early death occurred, for an early mortality rate of 5.2%. This patient had tricuspid atresia, good postoperative hemodynamics, and no arrhythmias. She was in stable condition for the first 48 hours postoperatively and then had a sudden deterioration while straining to defecate. A rapid and persistent desaturation was followed by bradycardia and then ventricular fibrillation. The postmortem examination showed an intraatrial tunnel of a uniform caliber of 20 mm, which had two residual interatrial shunts measuring 3 and 5 mm. There was significant narrowing of the SVC–right-pulmonary artery anastomosis. There were no late deaths.
The postoperative course of the survivors was relatively uneventful. One patient needed drainage of a chylopericardium. Pleural effusions requiring drainage for longer than 7 days were noted in 2 patients; in 1 of them, three thoracenteses were performed before the effusion subsided, and in the other, the drains remained for 10 postoperative days.
All but 3 patients were in sinus rhythm from the time of the operation. The 2 patients in whom the sinus node artery was divided remained in junctional rhythm for 3 and 5 days before reverting to sinus rhythm. They are in normal sinus rhythm 6.5 and 6 years later, respectively. One patient, who had undergone three previous operative procedures and who required extensive right atrial dissection and repair of the superior right atrial wall, had atrial tachyarrhythmias alternating with periods of junctional rhythm while being weaned from cardiopulmonary bypass. The patch was fenestrated, and bypass was discontinued with rapid atrial flutter, which continued postoperatively. The patient converted to sinus rhythm after treatment with amiodarone hydrochloride and remains in sinus rhythm 4 years later on a regimen of amiodarone. Yearly Holter monitoring has shown no documented supraventricular arrhythmias.
One patient had late onset of atrial flutter, which occurred 4 years after creation of a lateral tunnel and patch closure of a previous Blalock-Hanlon atrial septectomy. He is still being treated with a combination of nadolol and amiodarone and required insertion of a backup AAI pacemaker for sinus bradycardia. Regular Holter monitoring has shown only sinus rhythm and occasional atrial pacing.
No rhythm disturbances were noted on regular electrocardiographic and 24-hour electrocardiographic recordings in the other patients, none of whom had had previous surgical interventions involving the atrial free wall or septum.
Perioperative hemodynamic assessment was made in all patients, and there was no evidence of tunnel obstruction (see Table 1
). All patients have undergone cardiac echocardiography annually. If Doppler interrogation of the tunnel was unsatisfactory, the patient was referred for cardiac catheterization. Late hemodynamic studies and angiography were performed in 7 patients, and no tunnel obstruction was demonstrated (Table 2). A typical angiogram is shown in Figure 4. The first 4 patients had postoperative ventilation/perfusion scans, which showed normally matched perfusion and ventilation to both lungs.
View larger version (92K):
[in this window]
[in a new window]
|
Fig 4. . Angiocardiogram made 6 years after lateral tunnel construction demonstrates a wide, unobstructed tunnel without caval stenosis. The crista terminalis is shown by the arrow. (IVC = inferior vena cava; PA = pulmonary artery.)
|
|
One patient required aortic valve replacement for progression of aortic regurgitation 4 years after the lateral tunnel operation. He sustained a perioperative cerebrovascular accident; the motor deficit resolved, but he has learning difficulties and needs to attend special education classes. The other 17 children attend school on a full-time basis and are judged by their parents and cardiologists as meeting the criteria for New York Heart Association class 1.
|
Comment
|
|---|
The Fontan operation has undergone many modifications in the 26 years following its introduction by Fontan and Baudet [1]. In the last 9 years, the lateral tunnel procedure has become increasingly popular because of its applicability to a wide spectrum of pathologic entities, its relative technical ease, and its theoretic advantages from a hemodynamic standpoint. At Marie-Lannelongue Hospital, we adopted this technique in 1988 and used it selectively for patients in whom an atriopulmonary connection was considered less satisfactory, such as those with tricuspid atresia with normally related vessels or complex cardiac anatomies. We [5] reported our early results with this technique in 1990.
From the beginning, we concentrated on achieving a wide tunnel without distortions and adopted a technique aimed at minimizing the risk of injury to the sinus node and interatrial conduction pathways. Some of the details were deduced intuitively, but experimental data presented in the last few years appear to support our approach. In sewing the interatrial baffle, we noted that a potential for narrowing exists at three points. The first is at the superior end of the tunnel where the crista terminalis creates a ridge below the cavoatrial junction (see Fig 4). De Leval and coauthors [3] recommended anchoring the patch to the crista terminalis, but we chose to sew in a semicircle around the crista and a few millimeters outside it. The suturing then follows a line on the right atrial free wall and anterior to the crista to try to avoid a "waist" opposite the fossa ovalis, which is the second potential site for narrowing. Suturing along the trabeculated part of the right atrium requires great care to avoid residual interatrial communications. The third possible site for narrowing exists at the SVC–right atrial junction, as frequently there is a size discrepancy between the SVC and the larger IVC. This was noted by both De Leval's group [3] and Puga [4] and led to their internal incisions for enlargement. De Leval and colleagues acknowledged that the anteromedial enlargement is limited to the SVC itself to avoid dividing the crista terminalis or damaging the sinus node region. The posteromedial incision circumvents this problem, but to be effective, division of the posterior caval bundle, which is the continuation of the crista terminalis, is required. Norwood's hemi-Fontan incision divides Bachmann's bundle. Our group [5] chose to enlarge this region in a posterolateral direction to keep the incision away from the sinus node and its blood supply. In this way, the incision can be continued into the body of the right atrium to achieve the required diameter. The only death in this series occurred in a patient in whom the enlargement was inadequate, as it left the SVC diameter smaller than 66% of the IVC diameter.
A gratifying hemodynamic consequence of the posterolateral enlargement is a better distribution of perfusion to the two lungs. This was verified in the first 4 patients in whom ventilation/perfusion scans of the lungs were obtained. Recently, de Leval and associates [8] presented a report on computational fluid dynamics applied to the lateral tunnel operation. The report is an elegant experimental demonstration of a technique we have employed clinically for the last 8 years: the enlargement of the tunnel toward the right pulmonary artery ensures that more of the IVC flow is directed to the larger lung.
A second goal was to try to avoid the potential arrhythmias we anticipated with the Puga and de Leval techniques. We place the incision on the SVC as far away as possible from the region of the sinus node to try to prevent potential damage. Boineau and co-workers [9] described an atrial pacemaker complex centered around the anatomic sinoatrial node and demonstrated that the site of impulse origin changes depending on the different neural and humoral input. Sinus tachycardia originates from a region of the right atrium immediately anterior to the SVC–right atrial junction. Therefore, an incision in this area may impair the appropriate sinus tachycardiac-response with exercise. Dividing the arterial supply to the sinus node was considered by many [10, 11] to be a major cause of sinus node dysfunction. In patients with tricuspid atresia, which in our series as well as in most others represents the majority of patients, the sinus node artery arises more frequently from the left coronary artery than from the right. Battistessa and associates [12] demonstrated that in classic tricuspid atresia, 59% of patients show this type of arterial distribution. As the sinus node artery in this case passes over the roof of the left atrium to reach its destination, it is often unavoidably damaged by incisions placed on the medial aspect of the SVC. In experimental studies, Tamiya and colleagues [13] found that interruption of the sinus node feeding arteries leads to a junctional rhythm only in the presence of massive injury to preferential conduction pathways, but not otherwise. This would explain why in our 2 patients who had division of the sinus node artery, junctional rhythm was observed transiently; they reverted to sinus rhythm rapidly and had no further arrhythmias during a follow-up extending to 6 and 6.5 years.
In many series of patients followed up after atriopulmonary or cavopulmonary connection, atrial flutter is the most commonly observed tachyarrhythmia, and its prevalence increases with longer durations of follow-up [14–16]. In our series, 2 patients (10.5%) have had documented atrial flutter. Both had had two or more previous operations involving surgical incisions and suturing to the atrial wall or septum. In patient 6, atrial flutter developed after 4 years of stable sinus rhythm. He had undergone a Blalock-Hanlon atrial septectomy, which has been associated with an increased incidence of arrhythmias, notably atrial flutter [17]. Patient 13 had had three previous operations, one of which was a bidirectional Glenn anastomosis. The dissection required for the fourth operation resulted in laceration of the atrial wall, which required suturing, and this produced an area of conduction delay. Together with the long tunnel suture line, this provided a substrate for atrial flutter. The difficulties we encountered in this patient reinforced our belief that one-stage procedures are preferable in every instance. Recently Manning and associates [18] reported that staged operations increase the incidence of atrial arrhythmias after modified Fontan operations.
Rodefeld and coauthors [19] postulated that the lateral tunnel suture line establishes the anatomic substrate for atrial flutter by creating the conditions for slow conduction and unidirectional block. The same group [20] demonstrated in an acute experimental model that the inducibility of atrial flutter is increased by placing the suture line along the crista terminalis. Preservation of an intact crista terminalis allows rapid dispersion of the atrial impulse, thereby minimizing the effect of any conduction delay. We avoided suturing along the crista terminalis to allow the creation of a larger tunnel, but this may have paid dividends in creating fewer late rhythm problems (overall incidence, 11% after 5 years).
Weber and co-workers [21] reported an overall incidence of 30% of serious postoperative arrhythmias in 26 patients followed for a mean of 6.3 years after a Fontan operation and Fishberger and coauthors [22], an incidence of 16% in 334 patients followed for a mean of 5.3 years. In our series of lateral tunnel Fontan operations, there was an overall incidence of 11% of atrial flutter at a mean of 5.2 years, but these results are not comparable because of different patient populations in different institutions. However, patients who had had no previous atrial operations had no atrial flutter at a mean follow up of 5.2 years. This result encourages us to believe that the reduction in incidence of arrhythmia is real.
Damage to the sinus node can occur while sewing the baffle around the SVC orifice if the superior continuation of the crista terminalis is used to anchor sutures. Kurer and associates [23] demonstrated that there is a high degree of correlation between postoperative atrial flutter and sinus node dysfunction, as in the absence of sinus rhythm, lower atrial pacemakers take over atrial depolarization, which is no longer uniform, thus increasing the likelihood of initiation of reentry. We attempt to avoid the sinus node region altogether while enlarging the SVC–right atrial junction as well as while sewing in the baffle.
Another interesting point about incisions through the medial aspect of the SVC–right atrial junction was highlighted by Cox and coauthors [24] in a critical analysis of the original maze operation in which an incision is placed anterior to the SVC and across the interatrial septum. After this operation, some patients were observed to have no evidence of left atrial function on postoperative studies. Cox and colleagues explained this by the fact that the incision divides Bachmann's bundle, which is responsible for rapid activation of the left atrium, so that the two atria contract simultaneously. This ensures optimal ventricular filling on both the left and right sides of the heart. Division of this muscle bundle delays the left atrial activation considerably, and it may even be possible that the left atrium and the left ventricle become activated simultaneously, thus canceling the left atrial contribution to ventricular filling. Although we do not believe this has been proven clinically in patients after a modified Fontan procedure, it is likely that the consequences of dividing Bachmann's bundle would be more deleterious in a univentricular type of circulation.
In conclusion, we present a technique for creating a total cavopulmonary connection that ensures optimal hemodynamic results and avoids the sinus node area and the intraatrial and interatrial preferential conduction pathways. This minimizes the risks of postoperative atrial arrhythmias, particularly when there has been no previous atrial surgical procedure.
|
Footnotes
|
|---|
Address reprint requests to Dr Planche, Marie-Lannelongue Hospital, 133 Ave de la Résistance, 92350 Le Plessis-Robinson, France. (e-mail: monicaj{at}cts7.wustl.edu).
|
References
|
|---|
- Fontan F, Baudet S. Surgical repair of tricuspid atresia. Thorax 1971;26:240–8.[Abstract/Free Full Text]
- Puga FJ, Chiavarelli M, Hagler DS. Modifications of the Fontan operation applicable to patients with left A-V valve atresia or single A-V valve. Circulation 1987;76(Suppl 3):53–60.
- De Leval MR, Kilner P, Gewillig M, Bull C. Total cavo-pulmonary connection: a logical alternative to atrio-pulmonary connection for complex Fontan operations. J Thorac Cardiovasc Surg 1988;96:682–95.[Abstract]
- Puga FJ. The modified Fontan operation [Letter]. J Thorac Cardiovasc Surg 1989;98:150–1.[Medline]
- Planché C, Serraf AF, Lacour-Gayet F. Connexion cavo-pulmonaire totale. Presse Med 1990;19:129–31.[Medline]
- Driscoll DJ, Offord KP, Feldt R, Schaff HV, Puga FJ, Danielson GK. Five to fifteen-year follow-up after Fontan operations. Circulation 1992;85:469–96.[Abstract/Free Full Text]
- Warnes CA, Somerville J. Tricuspid atresia in adolescents and adults: current state and late complications. Br Heart J 1986;56:535–43.[Abstract/Free Full Text]
- De Leval MR, Dubini G, Miglivacca F, Jalali H, Pietrabissa R, Redington A. Use of computational fluid dynamics the design of surgical procedures: application to the study of competitive flows in cavopulmonary connections. J Thorac Cardiovasc Surg 1996;111:502–13.[Abstract/Free Full Text]
- Boineau JP, Canavan TE, Schuessler RB, Cain ME, Corr PB, Cox JL. Demonstration of a widely distributed atrial pacemaker complex in the human heart. Circulation 1988;77:1221–37.[Abstract/Free Full Text]
- Loeb JM, Enler DE, Randall WC, Moran JF, Bryjolfsson G. Cardiac arrhythmias after chronic embolization of the sinus node artery: alterations in parasympathetic pacemaker control. Circulation 1980;61:192–8.[Abstract/Free Full Text]
- El-Said GM, Gillette PC, Cooley DA, Mullins CE, McNamara DG. Protection of the sinus node artery in Mustard's operation. Circulation 1976;53:788–91.[Abstract/Free Full Text]
- Battistessa SA, Ho SY, Anderson RH, Smith A, Deverall PB. The arterial supply to the right atrium and the sinus node in classic tricuspid atresia. J Thorac Cardiovasc Surg 1988;96:816–22.[Abstract]
- Tamiya T, Yamashiro T, Hata A, Kuge K, Asano S, Sato T. Electrophysiologic study of dysrhythmias after atrial operations in dogs. Ann Thorac Surg 1992;54:717–24.[Abstract]
- Balaji S, Gewillig M, Bull C, de Leval MR, Deanfield J. Arrhythmias after the Fontan procedure. Comparison of total cavopulmonary connection and atriopulmonary connection. Circulation 1991;84(Suppl 3):162–7.
- Porter CJ, Battiste CE, Humes RA, et al. Risk factors for supraventricular tachyarrhythmias after the Fontan procedure for tricuspid atresia [Abstract]. Am Heart J 1986;112:645.
- Pearl JM, Laks H, Stein DG, Drinkwater DC, George BL, Williams RG. Total cavopulmonary anastomosis versus conventional modified Fontan procedure. Ann Thorac Surg 1991;52:189–96.[Abstract]
- Hamilton SD, Bartley TD, Miller RH, Schieber GL, Marriott HLJ. Disturbances in atrial rhythm and conduction following the surgical creation of an atrial septal defect by the Blalock-Hanlon technique. Circulation 1968;38:73–81.[Abstract/Free Full Text]
- Manning PB, Mayer JE, Wernovsky G, Fishberger SB, Walsh EP. Staged operation to Fontan procedure increases the incidence of sino-atrial node dysfunction. J Thorac Cardiovasc Surg 1996;111:833–40.[Abstract/Free Full Text]
- Rodefeld MD, Bromberg BI, Schuessler RB, Boineau JP, Cox JL, Huddleston CB. Atrial flutter after lateral tunnel construction in the modified Fontan operation. A canine model. J Thorac Cardiovasc Surg 1996;111:514–26.[Abstract/Free Full Text]
- Gandhi SK, Bromberg BI, Rodefeld MD, et al. Lateral tunnel suture line variation reduces atrial flutter after the modified Fontan operation. Ann Thorac Surg 1996;61:1299–309.[Abstract/Free Full Text]
- Weber HS, Hellenbrand WE, Kleinman CS, Perlmutter RA, Rosenfeld LE. Predictors of rhythm disturbances and subsequent morbidity after the Fontan operation. Am J Cardiol 1989;64:762–7.[Medline]
- Fishberger JB, Wernovsky G, Gentles TL, et al. Factors that influence the development of atrial flutter after the Fontan operation. J Thorac Cardiovasc Surg 1997;113:80–6.[Abstract/Free Full Text]
- Kurer CC, Tanner CS, Norwood WI, Vetter VL. Perioperative arrhythmias after Fontan repair. Circulation 1990;82(Suppl 4):190–4.
- Cox JL, Boineau JP, Schuessler RB, Jaquiss RDB, Lappas DG. Modification of the maze procedure for atrial flutter and atrial fibrillation. Rationale and surgical results. J Thorac Cardiovasc Surg 1995;110:473–95.[Abstract/Free Full Text]
This article has been cited by other articles:
|
|
|
|
 
W. I. Douglas, C. S. Goldberg, R. S. Mosca, I. H. Law, and E. L. Bove
Hemi-Fontan procedure for hypoplastic left heart syndrome: outcome and suitability for Fontan
Ann. Thorac. Surg.,
October 1, 1999;
68(4):
1361 - 1367.
[Abstract]
[Full Text]
[PDF]
|
|
|
Top
Abstract
Introduction
