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Surgical aspects of atrial arrhythmia

Right atrial ablation and anti-arrhythmic surgery in congenital heart disease

Chirurgische Aspekte des Vorhofflimmerns

Rechtsatriale Ablation und antiarrhythmische Chirurgie bei angeborenen Herzfehlern

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Abstract

Background

Atrial arrhythmias are frequently described in congenital heart disease.

Objectives

To provide a surgical perspective of anti-arrhythmic procedures and strategic approaches.

Methods

Discussion of the history of anti-arrhythmic treatments in congenital heart disease.

Results

Before the advent of the Maze procedure (first published in 1991), surgery mainly focused on patients with Wolff–Parkinson–White syndrome and also on arrhythmias in Ebstein’s malformation. Atrial septal defects (ASD) subsequently received more attention, i.e., in terms of atrial arrhythmia in the natural prognosis and the surgically modified course and in terms of surgical versus transcatheter approaches. Based on the background of various atrial arrhythmia mechanisms of ASD, several surgical procedures have been reported, ranging from the bilateral full Maze procedure to simple modification of right atriotomy. The so-called right atrial Maze procedure occupies a special position from the viewpoint of cardiology in acquired heart disease, especially in cases of frequently occurring right heart failure. In hearts with more complex structural abnormalities, a detailed understanding of the conditions to improve overall surgical outcome and develop future “anti-arrhythmic” strategies is necessary.

Conclusions

It is important to precisely specify factors in the individual cases, not only morphological diversity but also technical and strategic variations and their consequences. A variety of anti-arrhythmic surgical procedures are currently available. How and when to use which procedure requires professional insight and cautious clinical decision-making.

Zusammenfassung

Hintergrund

Vorhoftachykardien treten sehr häufig bei Patienten mit angeborenen Herzfehlern auf.

Zielsetzung

Dargestellt werden die chirurgische Perspektive bezüglich der verschiedenen antiarrhythmischen Strategien und ein Überblick über die zur Verfügung stehenden Optionen während herzchirurgischer Eingriffe.

Methoden

Es erfolgt die Besprechung der speziellen chirurgischen Behandlungsoptionen bei angeborenen Herzfehlern.

Ergebnisse

Vor der Einführung der „Maze-Operation“ (erstmals publiziert 1991) konzentrierte sich die Rhythmuschirurgie vorwiegend auf Patienten mit Wolff-Parkinson-White-Syndrom, aber auch auf Arrhythmien bei Ebstein-Anomalie. Später traten Vorhofseptumdefekte (ASD) mit den assoziierten Vorhofarrhythmien in den Vordergrund, entweder auf dem Boden des chirurgisch oder per Katheterintervention modifizierten Vorhofmyokards oder als natürliche Folge der Shuntbelastung. Vor dem Hintergrund der verschiedenen Arrhythmiemechanismen bei ASD wurde über eine Reihe von chirurgischen Vorgehensweisen berichtet, die von einer kompletten biatrialen Maze-Operation bis hin zur einfachen Modifikation der rechten Atriotomie reichen. Die sog. rechtsatriale Maze-Operation nimmt eine besondere Position hinsichtlich der „erworbenen“ Herzerkrankungen ein, insbesondere bei der häufig auftretenden Rechtsherzinsuffizienz. Bei komplexeren strukturellen Anomalien des Herzens ist ein detailliertes Verständnis der Verhältnisse erforderlich, um die chirurgischen Erfolgsraten zu verbessern und zukünftige „antiarrhythmische“ Strategien zu entwickeln.

Schlussfolgerung

Wichtig ist, die speziellen Faktoren im Rahmen der einzelnen Fälle genau zu erfassen, nicht nur hinsichtlich der morphologischen Unterschiede, sondern auch hinsichtlich der technischen und strategischen Variationen und deren Konsequenzen. Heutzutage steht eine Reihe von Methoden für die chirurgische antiarrhythmische Therapie zur Verfügung, deren Auswahl sorgfältig und mit entsprechendem fachlichem Verständnis erfolgen muss.

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  1. Consultant Cardiac Surgeon, Royal Brompton Hospital, Sydney Street, SW3 6NP, London, UK

    Hideki Uemura

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Uemura, H. Surgical aspects of atrial arrhythmia. Herzschr Elektrophys 27, 137–142 (2016). https://doi.org/10.1007/s00399-016-0434-6

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