title: Anatomically based ablation of atrial flutter in an acute canine model of the modified Fontan operation.
abstract: BACKGROUND
  Lateral tunnel total cavopulmonary connection, also called the modified Fontan operation, uses a baffle through the right atrium. We established, in an acute canine model, that atrial flutter after total cavopulmonary connection revolves around a line of conduction block imposed by the free wall lateral tunnel suture line. We hypothesized that a line of conduction block between the free wall total cavopulmonary connection suture line and the tricuspid anulus would interrupt atrial flutter in this model.
  
  
  OBJECTIVE
  Our objective was to determine whether a cryolesion placed between the free wall total cavopulmonary connection suture line and the tricuspid anulus would terminate atrial flutter in an acute canine model.
  
  
  METHODS
  Seven adult dogs underwent median sternotomy and institution of cardiopulmonary bypass. A suture line was placed through a right atriotomy to simulate total cavopulmonary connection lateral tunnel construction. Form-fitting 253-point biatrial endocardial mapping electrodes were placed via bilateral ventriculotomies. Atrial flutter was induced by atrial burst pacing. A cryothermal lesion was then placed between the free wall total cavopulmonary connection suture line and the tricuspid anulus in the low lateral right atrium (i.e., CRYO 1 procedure), and reinduction of atrial flutter was attempted. If atrial flutter was reinduced, the cryolesion was modified superiorly to include the caudal portion of the atriotomy (i.e., CRYO 2 procedure). Activation sequence maps were generated for sinus rhythms before and after the cryolesions were placed and for induced arrhythmias.
  
  
  RESULTS
  In all seven cases, atrial flutter was inducible after suture line placement, before placement of a cryolesion. The reentrant circuit incorporated both caval orifices in five of seven cases and was successfully ablated by the CRYO 1 approach in each case. Atrial flutter was not inducible after placement of the CRYO 2 lesion in the remaining two cases, in which breakthrough of the wave front occurred across the lateral tunnel suture line in the intercaval region. Activation sequence maps of sinus rhythm after placement of the cryolesions demonstrated a conduction block at the site of the lesion.
  
  
  CONCLUSIONS
  A linear cryothermal lesion placed between the free wall aspect of the total cavopulmonary connection suture line and the tricuspid anulus created a line of conduction block that successfully ablates atrial flutter in the canine model.
authors.affiliation: Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, Mo., USA.
authors.forename: M D
authors.initials: MD
authors.lastname: Rodefeld
authors.forename: S K
authors.initials: SK
authors.lastname: Gandhi
authors.forename: C B
authors.initials: CB
authors.lastname: Huddleston
authors.forename: B J
authors.initials: BJ
authors.lastname: Turken
authors.forename: R B
authors.initials: RB
authors.lastname: Schuessler
authors.forename: J P
authors.initials: JP
authors.lastname: Boineau
authors.forename: J L
authors.initials: JL
authors.lastname: Cox
authors.forename: B I
authors.initials: BI
authors.lastname: Bromberg
mesh_terms: D000208:Acute Disease; D000818:Animals; D001282:Atrial Flutter / Q000209:etiology* / Q000503:physiopathology / Q000601:surgery*; D002304:Cardiac Pacing, Artificial; D003452:Cryosurgery; D004285:Dogs; D004562:Electrocardiography; D018729:Fontan Procedure / Q000009:adverse effects / Q000379:methods*; D006325:Heart Atria / Q000503:physiopathology / Q000601:surgery; D006329:Heart Conduction System / Q000601:surgery; D013537:Sutures