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Anatomic biventricular repair by intraatrial and intraventricular re-routing in patients with left isomerism

Published online by Cambridge University Press:  01 July 2011

Hideki Uemura*
Department of Cardiovascular Surgery, National Cardiovascular Center, Osaka, Japan.
Toshikatsu Yagihara
Department of Cardiovascular Surgery, National Cardiovascular Center, Osaka, Japan.
Youichi Kawahira
Department of Cardiovascular Surgery, National Cardiovascular Center, Osaka, Japan.
Yoshiro Yoshikawa
Department of Cardiovascular Surgery, National Cardiovascular Center, Osaka, Japan.
Correspondence to: Hideki Uemura, MD, Department of Cardiovascular Surgery, National Cardiovascular Center, 5–7–1 Fujishirodai, Suita, Osaka 565–8565, Japan. Tel: 81–6–6833–5012; Fax: 81–6–6872–7486; E-mail:


Objective: To determine the efficacy of anatomic biventricular repair by a combination of intraatrial and intraventricular re-routing in patients with isomerism of the left atrial appendages. Methods: Anatomic biventricular repair by means of combined intraratrial and intraventricular re-routing was achieved in 5 of the 63 patients with left isomerism in whom we attempted a definitive surgical procedure. The inferior caval vein was interrupted in 3. The Mustard procedure was chosen for intraatrial redirection of blood in 4, and the Senning procedure in the other. Intraventricular re-routing was carried out via a right ventriculotomy in all patients, using an external conduit to reconstruct the morphologically right ventricular outflow tract. Results: One patient died one month after the procedure because of low cardiac output and bronchial bleeding. Obstruction across the superior caval venous channel occurred after the Senning procedure in this particular patient, related to the interrupted inferior caval vein draining via the azygous vein. The other 4 patients are currently doing well. Postoperative catheterization showed excellent cardiac performance, with no obstruction across the venous channels or the ventricular outflow tracts in these 4. No episode of significant archythmia has been noted, all patients having a regular atrial rhythm, although the P wave vector was unusual in each patient. Reoperation has been needed thus far in one patient, 128 months after the initial repair, because of obstruction of the external conduit. Conclusion: With precise recognition of the morphologic features, a combination of intraatrial and intraventricular re-routing can successfully be established in patients with isomeric left atrial appendages, with functional results in the intermediate term being reasonable.

Original Articles
Copyright © Cambridge University Press 2001

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1.Uemura, H, Ho, SY, Devine, WA, Kilpatrick, LL, Anderson, RH. Atrial appendages and venoatrial connections in hearts from patients with visceral heterotaxy. Ann Thorac Surg 1995; 60: 561569Google ScholarPubMed
2.Uemura, H, Ho, SY, Anderson, RH, Yagihara, T. Ventricular morphology and coronary arterial anatomy in hearts with isomeric atrial appendages. Ann Thorac Surg 1999; 67: 14031411Google Scholar
3.Uemura, H, Anderson, RH, Yagihara, T. Surgical implications in hearts with isomeric atrial appendages. In: Karp, RB, Laks, H, Wechsler, AS (eds). Advances in Cardiac Surgery, Vol. 7. St Louis: Mosby-Year Book, Inc., 1996: 101135Google Scholar
4.Uemura, H, Yagihara, T. Surgical treatment in patients with isomeric atrial appendages. In: Yacoub, M, Carpentier, AF (eds). Annual of Cardiac Surgery, 10th edn. London: Rapid Science Publishers, 1997: 105112Google Scholar
5.Kawashima, Y, Matsuda, H, Naito, Y, Yagihara, T, Kadoba, K, Matsuki, O. Biventricular repair of cardiac isomerism with common atrioventricular canal with the aid of an endocardial cushion prosthesis. J Thorac Cardiovasc Surg 1993; 106: 248254CrossRefGoogle ScholarPubMed
6.Hirooka, K, Yagihara, T, Kishimoto, H et al. , Biventricular repair in cardiac isomerism: report of seventeen cases. J Thorac Cardiovasc Surg 1995; 109: 530535CrossRefGoogle ScholarPubMed
7.Uemura, H, Yagihara, T, Kawashima, Y, Okada, K, Anderson, RH. The earliest site of atrial activation in patients with isomeric appendages. Br Heart J 1995; 74: 305309CrossRefGoogle ScholarPubMed
8.Ilbawi, MN, Deleon, SY, Backer, CL et al. , An alternative approach to the surgical management of physiologically cotrected transposition with ventricular septal defect and pulmonary stenosis or atresia. J Thorac Cardiovasc Surg 1990; 100: 410415CrossRefGoogle ScholarPubMed
9.Di Donato, RM, Troconis, CJ, Marino, B et al. , Combined Mustard and Rastelli operations – an alternative approach for repair of associated anomalies in congenitally corrected transposition in situs inversus {I, D, D}. J Thorac Cardiovasc Surg 1992; 104: 12461248Google ScholarPubMed
10.Yamagishi, M, Imai, Y, Hoshino, S et al. , Anatomic correction of atrioventricular discordance. J Thorac Cardiovasc Surg 1993; 105: 10671076CrossRefGoogle ScholarPubMed
11.Yagihara, T, Kishimoto, H, Isobe, F et al. , Double switch operation in cardiac anomalies with atrioventricular and ventriculoarterial discordance. J Thorac Cardiovasc Surg 1994; 107: 351358.CrossRefGoogle ScholarPubMed
12.Imai, Y, Sawatari, K, Hoshino, S, Ishihara, K, Nakazawa, M, Momma, K. Ventricular function after anatomical repair in patients with atrioventricular discordance. J Thorac Cardiovasc Surg 1994; 107: 12721283.CrossRefGoogle ScholarPubMed
13.Uemura, H, Yagihara, K. Anatomic biventricular repair by intraventricular and intraatrial rerouting in patients with discordant atrioventricular connecitons. In: Redington, A, Brawn, W, Deanfield, J, Anderson, RH (eds). The Right Heart in Congenital Heart Disease. London: Greenwich Medical Media Ltd, 1997: 237242Google Scholar
14.Dickinson, DF, Wilkinson, JL, Anderson, KR, Smith, A, Ho, SY, Anderson, RH. The cardiac conduction system in situs ambiguous. Circulation 1979; 59: 879885CrossRefGoogle Scholar
15.Ho, SY, Fagg, N, Anderson, RH, Cook, A, Allan, LD. Diposition of the atrioventricular conduction tissues in the heart with isomerism of the atrial appendages: its relation to congenital complete heart block. J Am Coll Cardiol 1992; 20: 904910CrossRefGoogle Scholar
16.Ho, SY, Seo, JW, Brown, NA, Cook, AC, Fagg, NL, Anderson, RH. Morphology of the sinus node in human and mouse hearts with isomerism of the atrial appendages. Br Heart J 1995; 74: 437442CrossRefGoogle ScholarPubMed
17.Momma, K, Linde, LH. Abnormal p wave axis in congenital heart disease associated with asplenia and polysplenia. J Elcetrocardiography 1969; 2: 395402Google ScholarPubMed
18.Momma, K, Takao, A, Shibata, T. Characteristics and natural history of abnormal atrial rhythms in left isomerism. Am J Cardiol 1990; 65: 231236CrossRefGoogle ScholarPubMed
19.Lev, M, Licata, RH, May, RC. The conduction system in mixed levocardia with ventricular inversion (corrected transposition). Circulation 1963; 28: 232237CrossRefGoogle ScholarPubMed
20.Thiene, G, Nava, A, Rossi, L. The conduction system in corrected transposition with situs inversus. Eur J Cardiol 1977; 6: 5770Google ScholarPubMed
21.Anderson, RH, Danielson, GK, Maloney, JD, Becker, AE. Atrioventricular bundle in corrected transposition. Ann Thorac Surg 1978; 26: 9596CrossRefGoogle ScholarPubMed