Ann Thorac Surg 2001;71:737-738
© 2001 The Society of Thoracic Surgeons
How to do it
Pericardial reinforcement after partial atrial resection in idiopathic enlargement of the right atrium
Afksendiyos Kalangos, MD, PhDa,
Ruth Ouaknine, MDa,
Sylvie Hulin, MDa,
Laurence Cohen, MDa,
Yves Lecompte, MDa
a Unit of Pediatric and Prenatal Cardiology, Institut Cardiovasculaire Paris Sud, Massy, France
Accepted for publication July 16, 2000.
Address reprint requests to Dr Kalangos, Clinic for Cardiovascular Surgery, University Hospital of Geneva, 24, rue Micheli-du-Crest, 1211 Geneva, 14 Switzerland
e-mail: afksendyios.kalangos{at}hcuge.ch
 |
Abstract
|
|---|
A 2-year-old boy in whom idiopathic enlargement of the right atrium was diagnosed in utero by fetal echocardiography underwent surgical intervention because of progression of right atrial dilatation. During operation, the lateral right atrial wall was externally reinforced after partial resection by approximating and fixing the neighboring autologous pericardium around the external circumference of the right atrium. This technique is a useful means of preventing recurrence of dilatation in histologically abnormal right atrial tissue that predisposes the patient to possible reintervention.
|
Introduction
|
|---|
Idiopathic enlargement of the right atrium is a rare abnormality characterized by the sole dilatation of the right atrium in the absence of valvulopathy, intracardiac shunts, and pulmonary hypertension. Partial resection of the lateral right atrial wall is a well-established surgical technique but does not prevent progressive postoperative dilatation of the histologically abnormal right atrial tissue. We describe herein a technique that consists of combining surgical resection with subsequent reinforcement of the lateral right atrial wall using neighboring autologous pericardium.
|
Technique
|
|---|
A 2-year-old boy in whom idiopathic enlargement of the right atrium was diagnosed by fetal echocardiography was referred to our institution because of progressive right atrial dilatation since birth, reaching a diameter of 74 x 76 mm on the last echocardiographic control. The tricuspid valve was normal, and Doppler studies showed mild tricuspid regurgitation on repeat echocardiograms. No other cardiac anomalies were found. Morphology of the left atrium and both ventricles was normal. Although the child was asymptomatic and had no arrhythmias, an operation was deemed necessary based on the rapid evolution of right atrial dilatation.
The patient underwent operation with the aid of cardiopulmonary bypass using ascending aortic and bicaval cannulation. A large ellipsoid portion of the lateral right atrial wall was resected after tightening caval snares around the venous cannulas while the heart was still beating. The edges of the right atriotomy were then sewn together with two 5-0 polypropylene running sutures. Caval snares were released, cardiopulmonary bypass discontinued, and the cannulas removed. Careful hemostasis was achieved with the administration of protamine. The right side of the pericardial sack, 1 cm above the right phrenic nerve, was approximated and fixed to the right atrium along the interatrial groove by a 5-0 polypropylene running suture. Two other running sutures were then begun from each of the two extremities of the first running suture and taken up along both cavo–right atrial junctions, approximating the corresponding part of the autologous pericardium to the right atrium (Fig 1). Both running sutures were then tied together on the left side of the right appendage, after approximating and fixing the pericardium along a line 5 mm away from the right atrioventricular groove. Histologic examination of the excised right atrial tissue revealed disruption of myofibrils, fibrosis, and lymphocytic infiltration.
View larger version (50K):
[in this window]
[in a new window]
|
Fig 1. Surgical technique of reinforcement of the partially resected lateral right atrial wall using neighboring autologous pericardium.
|
|
|
Comment
|
|---|
Idiopathic enlargement of the right atrium is a rare cardiac anomaly that can be associated with episodes of atrial dysrhythmias, intraatrial thrombus formation with subsequent pulmonary embolization, pericardial effusion, secondary right ventricular compression, and sudden death [1–4]. Surgical resection of a large part of the right atrial tissue to normalize right atrial dimensions was first advocated in symptomatic patients complaining of dyspnea, palpitations, fatigability, and syncope [5]. Surgical intervention has produced good midterm results by treating severe forms of atrial dysrhythmias refractory to antiarrhythmic drugs [6]. Nevertheless, the potentially life-threatening nature of secondary right ventricular compression possibly compromising right ventricular output, pulmonary embolization of an intraatrial thrombus, and rupture of the dilated right atrium incline us to adopt, even in asymptomatic patients, the systematic partial resection of the dilated right atrium. However, the natural outcome of the remaining histologically abnormal atrial tissue, usually exhibiting chronic inflammation and disruption of myofibrils replaced by patchy fibroelastosis, and the rate of recurrent atrial dilatation remain unclear owing to the rarity of this anomaly and perhaps to the lack of systematic follow-up of patients undergoing operations [7]. Some surgeons have already advocated replacing the resected right atrial wall with pericardium to preserve normal wall consistency and avoid recurrent right atrial dilatation [8]. Our alternative technique described herein can prevent recurrent postresection right atrial dilatation by externally reinforcing the lateral right atrial wall using neighboring autologous pericardium as a shield. Moreover, this method is advantageous in that the endocardial surface of the right atrium remains in contact with blood flow and it allows for primary closure of the pericardium as the integrity of the pericardial sack is conserved.
|
References
|
|---|
-
Sheldon W.C., Johnson C.D., Favaloro R.G. Idiopathic enlargement of the right atrium. Am J Cardiol 1969;23:278-284.[Medline]
-
Beder S.D., Nihill M.R., McNamara D.G. Idiopathic dilation of the right atrium in a child. Am Heart J 1982;103:134-137.[Medline]
-
Rutledge J., Robertson M.A., Kantoch M., Dyck J. Idiopathic dilation of the right atrium: case report and survey of the literature. Can J Cardiol 1997;13:855-857.[Medline]
-
Kozelj M., Angelski R., Pavcnik D., Zorman D. Idiopathic enlargement of the right atrium. Pediatr Cardiol 1998;19:420-421.[Medline]
-
Blaysat G., Villain E., Marçon F., et al. Pronostic et évolution de la dilatation idiopathique de l’oreillette droite chez l’enfant. Etude coopérative à propos de 15 cas. Arch Mal Coeur 1997;90:645-648.
-
Marin-Garcia J., Allen R.G. Idiopathic dilatation of the right atrium: post-operative follow-up in a child. J Pediatr Surgery 1983;18:196-198.[Medline]
-
Terada T., Oiwake H., Nakanuma Y., Ohta G., Nishino T. An autopsy case of idiopathic enlargement of the right atrium and a review of the literature. Acta Pathol Jpn 1988;38:361-370.[Medline]
-
Zeebregts C.J.A.M., Hensens A.G., Lacquet L.K. Asymptomatic right atrial aneurysm: fortuitous finding and resection. Eur J Cardiothorac Surg 1997;11:591-593.[Abstract]
Top
Abstract
Introduction
