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Ann Thorac Surg 2005;79:388
© 2005 The Society of Thoracic Surgeons

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Correspondence

Conduction Disturbance After Shutdown of the Sinus Node Artery

^a Division of Cardiovascular Surgery, Jichi Medical School 3311-1, Yakushiji Minami-kawachi, Tochigi 329-0498, Japan

tcvmisa{at}jichi.ac.jp

To the Editor:

We read with great interest the study by Berdajs and associates [1] and the invited commentary by Kovács [2]. The authors analyzed 50 human hearts from cadavers without previous pathological alterations and found that the sinus node artery crossed the superior posterior border of the interatrial septum in 54% of the hearts. On the basis of morphological and clinical results, Berdajs and co-workers concluded that the risk of intraoperative damage to the sinus node artery during a superior transseptal approach to the mitral valve is high.

We prefer the superior transseptal approach to the conventional transseptal approach or a right-sided left atriotomy. In 1999, we [3] reported a retrospective study of conduction disturbances after the superior transseptal approach for mitral valve operations in 52 consecutive patients seen from October 1996 to October 1998. We noted some supraventricular conduction disturbances such as transient prolonged P-R intervals for up to 2 weeks in 25 patients who maintained sinus rhythm. However, perioperative electrocardiograms for all patients and Holter monitors on 17 patients 6 to 12 months after operation showed no medically intractable arrhythmias or supraventricular arrhythmias exceeding 3% of the total beats. None of our patients needed pacemaker implantation. Of 113 patients, the original 52 plus an additional 61 patients with mitral valve disease requiring surgical intervention or a left atrial tumor seen from November 1998 to December 2001, none needed pacemaker implantation; 64 of 66 patients who were in sinus rhythm preoperatively maintained sinus rhythm postoperatively; and 7 of 47 patients in atrial fibrillation regained sinus rhythm postoperatively [4].

As Berdajs and associates pointed out, damage to the sinus node artery can cause conduction disturbances and supraventricular arrhythmias. However, this condition is transient and without clinically troublesome issues. We hypothesize that newly developed collateral blood flow to the sinus node or an altered cardiac conduction system caused by a superior transseptal approach might contribute to transient conduction disturbances. The numerous anastomoses between the surrounding atrial arteries and the arteriolar network of the sinus node, which were mentioned by Kovács would help lead to preferable clinical outcomes. Cardiac surgeons need to take into consideration the potential risk after a superior transseptal approach, as implied by Berdajs and colleagues. However, most arrhythmias are transient and can be controlled by ordinary perioperative measures.

References

1. Berdajs D, Patonay L, Turina MI. The clinical anatomy of the sinus node artery. Ann Thorac Surg. 2003;76:732–735[Abstract/Free Full Text]
2. Kovács GS. The clinical anatomy of the sinus node artery. Ann Thorac Surg. 2003;76:735–736[Free Full Text]
3. Misawa Y, Fuse K, Kawahito K, Saito T, Konishi H. Conduction disturbances after superior septal approach for mitral valve repair. Ann Thorac Surg. 1999;68:1262–1265[Abstract/Free Full Text]
4. Misawa Y, Saito T, Konishi H, et al. Superior septal approach for mitral valve surgery or left atrial tumor. Jpn J Thorac Cardiovasc Surg. 2002;50(Suppl):404

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