(Circulation. 1995;92:304-308.)
© 1995 American Heart Association, Inc.
Articles |
From the State University of New York-Health Science Center, Syracuse, NY.
Correspondence to Rae-Ellen W. Kavey, MD, Division of Pediatric Cardiology, SUNY-Health Science Center, 725 Irving Ave, Room 804, Syracuse, NY 13210.
| Abstract |
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Methods and Results The Fontan group consisted of 17 patients
repaired at 7.8±3.1 years of age (mean±SD): 11 for tricuspid or
pulmonary atresia (TA/PA) and 6 for single ventricle. The TCPC
group consisted of 19 patients repaired at 5.1±3.2 years of age
(mean±SD) (P<.001): 9 for TA/PA, 4 for single ventricle,
and 6 for hypoplastic left heart syndrome. Mean follow-up after
Fontan was 7.7±2.7 years versus 2.8±1.6 years for TCPC
(P<.001). Preoperative ECGs on all TCPC patients showed
sinus rhythm (SR), whereas 16 of 17 Fontan patients had SR and one had
nonsinus atrial rhythm (NSAR) since birth. On the first postdischarge
ECG, 12 of 19 TCPC patients (63%) were in SR, 4 were in junctional
rhythm (JR), and 3 were in NSAR. In comparison, 15 of 17 Fontan
patients (88%) were in SR with 1 of 17 in NSAR and 1 in
supraventricular tachycardia (P<.05
with
2 test). By 2 years postoperatively, only 6
of 15 TCPC patients available for follow-up (40%) were in SR, with
7 of 15 in JR and 2 of 15 in NSAR. By contrast, 13 of 17 Fontan
patients (76%) remained in SR, with 1 in NSAR and 3 in JR
(P<.05 with
2 test). TCPC patients
with loss of SR did not differ from other patients in the group in age
at repair, preoperative diagnosis, or surgeon performing the
procedure.
Conclusions This significant incidence of loss of SR temporally related to surgery suggests that operative compromise of the sinus node area is common with TCPC.
Key Words: Fontan procedure electrocardiography surgery sinoatrial node
| Introduction |
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| Methods |
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ECG Evaluation
For both groups, all ECGs from initial
diagnosis to last
available postoperative tracing were reviewed. The proximate
preoperative tracing, the first postdischarge tracing, the 2-year
postoperative tracing, and the last available ECG were analyzed
for cardiac rhythm, P wave axis, and P wave morphology.
Ambulatory 24-hour ECGs were analyzed for basic rhythm and for the presence of arrhythmia. Sinus rhythm was diagnosed when present for >90% of the 24-hour period. JR was diagnosed when present for >10% of the 24-hour period. Atrial and ventricular ectopic beats (>50 per hour) and all episodes of arrhythmia were recorded.
Statistical Analysis
Univariate comparisons of descriptive
data in the
two groups were made with Student's t tests. Differences in
proportion between the two groups were analyzed by use of
2 analysis.
| Results |
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Clinical characteristics of the
patients in the two groups are
summarized in Table 1
. No Fontan patient had an
underlying diagnosis of HLHS, whereas this diagnosis was associated
with 31% of those undergoing TCPC. Prior palliative procedures in both
groups are shown in Table 2
. At ultimate palliation, 2
patients in the TCPC group had placement of an intact intracardiac
conduit from inferior vena cava to right pulmonary
artery, whereas in the remaining patients, a lateral expanded
polytetrafluoroethylene channel including a
portion of the right atrial posterior wall was created. TCPC patients
were significantly younger than Fontan patients both at repair and at
postoperative evaluation.
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Preoperative ECGs
Findings on the last outpatient ECG before
surgery are shown in
Table 3
and Fig 1
. All 19 TCPC patients
were in sinus rhythm. Sixteen of 17 Fontan patients were in sinus
rhythm, and 1 was in NSAR, which had been present since birth. One
Fontan patient had manifested intermittent JR on office ECGs before
open repair. No NSAR or JR was documented preoperatively on standard
ECGs in any TCPC patient.
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Postdischarge ECG
The first ECG after hospital discharge was
recorded a mean of
28 days after TCPC and 24 days after Fontan (P=NS). ECG
findings are summarized in Table 3
and Fig 1
.
Fifteen of 17 Fontan
patients (88%) were in sinus rhythm, with one in NSAR; the child with
preoperative NSAR presented with
supraventricular tachycardia on the first
postoperative visit. In comparison, only 12 of 19 TCPC patients (63%)
were in sinus rhythm, with 3 in NSAR and 4 in JR (P<.05
with
2 test) (Fig 2
). One patient
with tricuspid atresia and 2 with single ventricle presented
with NSAR after surgery; JR occurred in 1 patient each with tricuspid
and pulmonary atresia and 2 with HLHS.
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Analysis of P-wave morphology
indicated a significant decrease
in P-wave amplitude for those patients in sinus rhythm after TCPC (Fig
3
). This difference was statistically significant when
compared with preoperative tracings (P<.001). No
significant change in P-wave amplitude was noted after Fontan (Fig
4
). P-wave changes are summarized in Table 4
.
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Intermediate-Term ECG Findings: 2 Years Postrepair
Fifteen
TCPC patients were followed up for at least 2 years; 1
patient with chronic pleural effusion and hypogammaglobulinemia died of
sepsis 5 months after surgery, and 3 patients have been followed up for
1 to 16 months. All 17 Fontan patients were followed up for more than 2
years. ECG findings at 2 years after repair are summarized in Fig
5
. Standard ECGs in only 6 of the 15 available TCPC
patients (40%) showed sinus rhythm, compared with 13 of 17 Fontan
patients (76%) (P<.05 with
2 test).
In the TCPC group, 2 patients who had NSAR early after repair now had
JR, 1 patient with early sinus rhythm now had NSAR, and 1 patient with
early sinus rhythm now had JR with recurrent atrial flutter. In the
Fontan group, 3 patients had developed JR on standard ECGs, including
the child with intermittent JR on preoperative tracings; the patient
with NSAR since birth remained in this rhythm. Low P-wave amplitude
persisted in the TCPC patients (Figs 2
, 3
, and
4
).
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Late Follow-up
No further change in ECGs was recorded in the
13 TCPC patients
followed for an additional 1 to 36 months (mean, 18 months) beyond the
initial 2-year follow-up period. In the Fontan group, all patients
were followed up for a mean of 70 months (range, 12 to 132 months)
beyond the initial 2-year period. Over that time period, 1 additional
patient developed JR 11 years after repair; 1 with JR developed
recurrent atrial flutter/fibrillation and died suddenly 8 years after
Fontan; 1 required transplant for intractable protein-losing
enteropathy 4 years after Fontan; and 1 died with respiratory failure 3
years after Fontan. On the last ECG, recorded a mean of 9.2 years
postrepair, 11 of 14 Fontan survivors (79%) were in sinus rhythm, 1
remained in NSAR, and 2 were in JR. In comparison, the last ECG on 18
of 19 TCPC survivors showed sinus rhythm in only 6 (33%) despite the
significantly shorter mean follow-up period of 2.8 years.
Ambulatory ECGs
Fourteen of 19 TCPC patients and 15 of 17
Fontan patients have
undergone at least one postoperative ambulatory ECG. Cardiac rhythm
findings are summarized in Fig 6
. In no patient did the
ambulatory ECG document a rhythm pattern not recorded on standard
ECG. In 1 TCPC patient with JR, sinus arrest with prolonged pauses
greater than 3 seconds was recorded during sleep after TCPC (Fig
7
).
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Tachyarrhythmias
Clinical tachyarrhythmias are recorded in
Table 5
. One TCPC patient with JR has had recurrent refractory
atrial flutter. Four Fontan patients have experienced episodes of
atrial flutter/fibrillation; one of these four patients died suddenly 8
years after surgery. One additional Fontan patient has had recurrent
supraventricular tachycardia.
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| Discussion |
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The TCPC was developed to reduce right atrial pressures and volumes known to contribute to tachyarrhythmias that occur in as many as 50% of patients after Fontan.7 8 9 Hemodynamic results early after TCPC have been favorable, and tachyarrhythmias in the early postoperative period have occurred at lower frequency.10 In this series, postoperative tachyarrhythmias in the intermediate term also occurred at a lower frequency after TCPC than after Fontan, although this difference did not reach statistical significance. No other study documenting loss of sinus rhythm after TCPC has been reported, but most series have looked primarily at the immediate postoperative period,11 focused on tachyarrhythmias10 and/or included a combination of Fontan and TCPC patients.9 11 References to sick sinus syndrome10 11 and to the need for pacemakers because of sinus node dysfunction12 have appeared in reports of surgical results. In our series, loss of sinus rhythm was not associated with any specific diagnosis, younger age at repair, or any one of the five surgeons who performed the operations. The proximity of the sinus node area to the TCPC repair represents a biologically plausible basis for the implication of the surgical repair itself in causation.
The decrease in P-wave amplitude recorded on ECGs in patients after TCPC is also reminiscent of changes seen after Mustard. The etiology of this is unknown, but it may be related to alterations in conduction in the presence of intra-atrial prosthetic material and/or to extensive atrial suture lines. After Mustard, low P-wave voltage often preceded loss of sinus rhythm, and rhythm abnormalities occurred at increased incidence as duration of follow-up increased.13 This association and the progressive loss of sinus rhythm in the first 2 years after surgery in this series suggest that prospective follow-up for atrial conduction abnormalities as well as tachyarrhythmias is important after TCPC.
In patients with functional single ventricle, TCPC confers important hemodynamic advantages over the traditional Fontan procedure. If the findings in this series are documented in a larger group of patients, consideration should be given to modification of the TCPC procedure to avoid the sinus node area.
| Selected Abbreviations and Acronyms |
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| Acknowledgments |
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| References |
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2. Pearl RM, Laks H, Stein DG, Drinkwater DC, George BL, Williams RG. Total cavopulmonary anastomosis versus conventional modified Fontan procedure. Ann Thorac Surg. 1991;52:189-196. [Abstract]
3. Deanfield J, Comm J, Macartney F, Cartwright T, Douglas J, Drew J, deLeval M, Stark J. Arrhythmia and late mortality after Mustard and Senning operation for transposition of the great arteries. J Thorac Cardiovasc Surg. 1988;96:569-576. [Abstract]
4. Flinn CJ, Wolff GS, Macdonald D II, Campbell RM, Borkat G, Casta A, Hordof A, Hougen TJ, Kavey RE, Kugler J, Liebman J, Greenhouse J, Hees P. Cardiac rhythm after the Mustard operation for complete transposition of the great arteries. N Engl J Med. 1984;310:1635-1642. [Abstract]
5. Gillette PC, Kugler JD, Garson A, Gutgesell HP, Duff DF, McNamara DG. Mechanisms of cardiac arrhythmias after the Mustard operation for transposition of the great arteries. Am J Cardiol. 1980;45:1225-1230. [Medline] [Order article via Infotrieve]
6. Scott LP, Saalouke MG, Shapiro SR, Rios JC, Perry LW. Sudden unexpected death following Mustard's procedure for d-transposition of the great arteries. Circulation. 1976;54(suppl II):II-89. Abstract.
7. Weber HS, Hillenbrand WE, Kleinman CS, Perlmutter RA, Rosenfeld LE. Predictors of rhythm disturbances and subsequent morbidity after the Fontan operation. Am J Cardiol. 1989;64:762-767. [Medline] [Order article via Infotrieve]
8. Chen S, Nouri S, Pennington DG. Dysrhythmias after the modified Fontan procedure. Pediatr Cardiol. 1988;9:215-219. [Medline] [Order article via Infotrieve]
9.
Gewillig M, Wyse RK, deLeval MR, Deanfield JE.
Early and late arrhythmias after the Fontan operation:
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J. 1992;67:72-79.
10. Balaji S, Gewillig M, Ball C, deLeval MR, Deanfield JE. Arrhythmias after the Fontan procedure: comparison of total cavopulmonary connection and atriopulmonary connection. Circulation. 1991;84(suppl III):III-162-III-167.
11. Kurer CC, Tanner CS, Norwood WI, Vetter VL. Perioperative arrhythmias after Fontan repair. Circulation. 1990;82(suppl IV): IV-190-IV-194.
12.
Farrell PE, Chang AC, Murdison KA, Baffa JM, Norwood
WI, Murphy JD. Outcome and assessment after the modified Fontan
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13. Hayes CJ, Gersony WM. Arrhythmias after the Mustard operation for transposition of the great arteries: a long-term study. J Am Coll Cardiol. 1986;7:133-137.[Abstract]
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