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Ann Thorac Surg 2007;84:1072-1073
© 2007 The Society of Thoracic Surgeons

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Correspondence

The Need for Pacemaker Implantation After Using a Superior Transseptal Approach: Letter 1

Division of Cardiovascular Surgery, Jichi Medical University, Yakushiji 3311-1, Shimotsuke, Tochigi, 329-0498 Japan

(Email: tcvmisa{at}jichi.ac.jp).

To the Editor:

We read with great interest Lukac and colleagues’ [1] article in which they analyzed 150 patients after mitral valve surgery that used the superior transseptal approach and compared them with 427 patients operated on by the left atrial approach. They concluded that the superior transseptal approach has a higher risk of clinically significant sinus node dysfunction than the left atrial approach, but that the risk of pacemaker implantation because of atrioventricular conduction disturbances was not different between the groups.

The conventional approach for mitral valve surgery or left atrial tumor resection includes a left atriotomy from the right side and a right atrial transseptal approach. These approaches do not sacrifice the sinus node artery. However the superior transseptal approach does sacrifice the artery, causing potential risks for postoperative arrhythmias, such as supraventricular arrhythmias and atrioventricular conduction disturbances [2]. On the other hand, as the authors mentioned that the superior transseptal approach offers an excellent operative view even when the left atrium is small. The better the operative view, then the safer and more certain is the operative procedure. For this reason, we often choose the superior transseptal approach for mitral valve surgery or left atrial tumor resection.

In 1999 we presented our clinical experiences with the superior transseptal approach detailing 52 consecutive patients with a mean follow-up period of 15 ± 8 months. We do not extend onto the superior portion of the left atrium behind the aorta, but we go parallel to the superior vena cava. Our incision length is limited to 2 cm. Postoperative PR intervals on the electrocardiogram in patients with sinus rhythms increased for the first week, began to decrease within 2 weeks, and returned to a normal range by 6 months. None of our patients needed pacemaker implantation. We hypothesized that the conduction delay was caused by sacrificing the sinus node artery, and that the postoperative development of collateral blood flow contributed to the normalization of the delay.

Among the patients of Lukac and colleagues [1], 11 had pacemakers implanted by 2 weeks. However, in our patients, postoperative bradycardia was postoperatively managed with a transient pacemaker for 2 weeks. The difference in approaches would lead to the higher rate for pacemaker implantation in patients. Long after the operation, what is the rhythm status in patients who had a pacemaker implanted early after operation? It would also be interesting to know if there are any procedure differences regarding the incision onto the superior portion of the left atrium between Lukac and colleagues’ [1] and our study. Lukac and colleagues [1] presented informative and instructive clinical results; we should recognize that the superior transseptal approach brings with it potential risks of conduction disturbances.

	References

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1. Lukac P, Hjortdal VE, Pedersen AK, Mortensen PT, Jensen HK, Hansen PS. Superior transseptal approach to mitral valve is associated with a higher need for pacemaker implantation than the left atrial approach Ann Thorac Surg 2007;83:77-82.[Abstract/Free Full Text]
2. Takeshita M, Furuse A, Kotsuka Y, Kubota H. Sinus node function after mitral valve surgery via the transseptal superior approach Eur J Cardiothorac Surg 1997;12:341-344.[Abstract]

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				P. Lukac, V. E. Hjortdal, and P. S. Hansen Reply Ann. Thorac. Surg., September 1, 2007; 84(3): 1073 - 1074. [Full Text] [PDF]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Yoshio Misawa Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Misawa, Y. Articles by Konishi, H. Search for Related Content PubMed PubMed Citation Articles by Misawa, Y. Articles by Konishi, H. Related Collections Electrophysiology - arrhythmias Related Article