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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 Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Carlo F. Marcelletti Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Marcelletti, C. F. Search for Related Content PubMed Articles by Marcelletti, C. F. Related Collections Related Article

Ann Thorac Surg 1999;68:1848
© 1999 The Society of Thoracic Surgeons

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Invited Commentaries

^a Department of Pediatric Cardiac Surgery, Hesperia Hospital, Via Arqua 80, 41100 Modena, Italy

Invited commentary

The increase in right atrial size and pressure that occurs in the setting of an atriopulmonary Fontan has been hypothesized to cause turbulence and energy loss, compression of the pulmonary veins, coronary sinus hypertension, arrhythmias, and atrial thrombus.

Management is for the most part limited to orthotopic heart transplantation or revision of the Fontan connection.

In recent years an increasing number of centers have adapted conversion to an extracardiac conduit total cavopulmonary anastomosis.

In the series of patients with Fontan revision, studied by Marcelletti and associates, only 2 were free from atrial dysrythmias (one third had supraventricular tachycardia, one third atrial flutter or fibrillation, and one third atrioventricular conduction abnormalities).

Forty percent of patients with rhythm disturbances underwent intraoperative treatment by mapping with ablation of arrhythmic circuits and/or antitachycardia pacemaker implantation or Maze procedure. In the remaining patients prerevision arrhythmias improved spontaneously or could be easily controlled by medical therapy.

Atrial tachyarrhythmias (almost invariably present is a failing Fontan with giant right atrium and coronary sinus hypertension) seem to improve regularly after revision to an extracardiac cavopulmonary anastomosis, probably from relief of atrial distension and maximal reduction of the right atrial wall.

Although our experience indicates that intraoperative ablation or Maze procedure are not fundamental in obtaining rhythm control, I believe that all reports, such as this one by Dr Nomura, should be analyzed with great attention, searching for increasing evidence that also "electrical" manipulation of right atrial wall should be part of a well-planned Fontan revision.

One point should, nevertheless, be clear to all cardiologists and cardiac surgeons involved with the care of post-Fontan patients: the appearance of supraventricular arrhythmias is a clear sign that the atriopulmonary anastomosis is functionally failing and therefore requires early revision.

Prolonged attempts with antiarrhythmic drugs usually end up as a waste of time and a delay to appropriate surgical therapy.

Related Article

The failing Fontan with atrial flutter: a successful surgical option

Fumikazu Nomura, Kirsten Finucane, Warren Smith, and Alan R. Kerr
Ann. Thorac. Surg. 1999 68: 1845-1848. [Abstract] [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 Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Carlo F. Marcelletti Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Marcelletti, C. F. Search for Related Content PubMed Articles by Marcelletti, C. F. Related Collections Related Article