Moving the Goalposts
Prevention of Atrial Arrhythmias After Congenital Heart Surgery
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Atrial arrhythmias have for decades been recognized as a principal late complication of the Fontan procedure. A specific connection between the 2 was recognized soon after the procedure emerged as a standard clinical pathway for patients with single ventricle physiology. Intra-atrial reentrant tachycardia (IART) is a major cause of morbidity in the form of recurring symptoms and need for medical intervention in these patients.1 Early on, risk factors for future IART were identified, most notably the occurrence of atrial arrhythmia in the perioperative period.2 The relationships between organized atrial tachycardias and comorbidities such as thromboembolism, heart failure, and mortality have been investigated and are now well established.3 These observational associations were established through retrospective studies, which could not allow for attribution of causality. Despite this weakness of this type of clinical evidence, IART has been clearly identified in multiple concordant studies as one of the bad actors predictive of poor long-term outcome in patients undergoing the Fontan procedure.
See Article by Law et al
This association of arrhythmia with a specific congenital heart operation has been vigorously pursued by surgeons and electrophysiologists as a potentially modifiable factor, which could perhaps be exploited in an attempt to avoid late occurrence of IART. There is a well-known relationship between atrial myocardial injury and atrial flutter, and experimental surgical models that mimic the atrial manipulations used by congenital heart surgeons are reliable and potent promoters of reentrant tachycardia. This suggests that carefully designed changes in how the atrial myocardium is managed at the time of Fontan surgery could perhaps preempt and favorably alter the observed arrhythmogenic process.
One such approach proposed as means by which arrhythmia prophylaxis (along with other theoretical hemodynamic benefits) could be achieved is to exclude the right atrium altogether, by using an extracardiac conduit to complete …