title: Left-sided atrial flutter: characterization of a novel complication of pediatric lung transplantation in an acute canine model.
abstract: BACKGROUND
  Postoperative atrial flutter has been observed in approximately 10% of children undergoing lung transplantation at our institution. We hypothesized that the left atrial anastomoses made to establish pulmonary venous continuity provide the primary electrophysiologic substrates for atrial flutter.
  
  
  OBJECTIVE
  Our objectives were (1) to determine whether the left atrial suture lines alone are sufficient to produce atrial flutter in an acute canine model of lung transplantation and (2) to characterize any resulting reentrant circuits to surgically ablate the atrial flutter.
  
  
  METHODS
  Supported by cardiopulmonary bypass, adult dogs (n = 10) underwent bilateral pneumonectomies. The left atrial anastomotic suture lines were simulated by dividing the tissue between the ostia of the transected superior and inferior pulmonary veins and closing the resulting defects. Bilateral suture lines were placed in group 1 (n = 6) to simulate bilateral lung transplantation. In group 2 (n = 4), only a left-sided suture line was placed to represent single lung transplantation. Unipolar 253-point biatrial endocardial mapping electrodes were inserted via bilateral ventriculotomies. Atrial flutter was induced by atrial burst pacing, and activation sequence maps were generated. In five of six cases in group 1, a T-incision connecting the two suture lines and the mitral anulus was then made. In group 2, a single incision from the suture line to the mitral anulus was performed in each case. Burst pacing was subsequently repeated.
  
  
  RESULTS
  Atrial flutter could not be induced after bypass alone in any case. After simulated lung transplantation, sustained atrial flutter was reproducibly induced in 10 of 10 dogs. The mean cycle length in all dogs was 133 +/- 7 msec. There was no significant difference in mean cycle length or activation sequence patterns between groups 1 and 2. The reentrant circuit was confined to the left atrium. Each simulated left atrial anastomosis created a zone of conduction block around which circus movement could occur. In group 1, either suture line functioned as the central obstacle. Atrial flutter was terminated in five of five dogs in group 1 by means of the T-incision and in all four dogs in group 2 with the incision connecting the suture line to the mitral anulus.
  
  
  CONCLUSIONS
  (1) In an acute canine model of lung transplantation, each left atrial suture line alone provides an electrophysiologic substrate for atrial flutter by creating a zone of conduction block around which circus movement can occur. (2) Extending this zone of block to the mitral anulus, together with interruption of the isthmus of tissue between the two suture lines present after bilateral lung transplantation, terminates the atrial flutter in this model and may have an application prophylactically at the time of lung transplantation in children to prevent postoperative atrial flutter.
authors.affiliation: Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, Mo., USA.
authors.forename: S K
authors.initials: SK
authors.lastname: Gandhi
authors.forename: B I
authors.initials: BI
authors.lastname: Bromberg
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: C B
authors.initials: CB
authors.lastname: Huddleston
mesh_terms: D000714:Anastomosis, Surgical; D000818:Animals; D001282:Atrial Flutter / Q000209:etiology* / Q000503:physiopathology; D002304:Cardiac Pacing, Artificial; D002648:Child; D004285:Dogs; D004562:Electrocardiography; D006325:Heart Atria / Q000601:surgery; D006329:Heart Conduction System / Q000503:physiopathology; D006801:Humans; D016040:Lung Transplantation / Q000009:adverse effects*; D013537:Sutures