title: The right auricle tunnel as intercaval tunnel in total cavopulmonary connection may prevent atrial flutter.
abstract: OBJECTIVE
  Total cavopulmonary connection (TCPC) is a routine operation for palliation of children with cardiac anomalies in whom biventricular repair is impossible. The original technique consists of the creation of a semi-prosthetic intercaval tunnel. A substantial proportion of these patients develop atrial flutter. We developed a technique for creating an intercaval tunnel that uses the tissue of the right auricle as intercaval tunnel. This technique avoids suture lines in the neighbourhood of the blood supply of the sinus node and leaves the terminal crest free. Since atrial flutter frequently occurs after Mustard and Senning operations in which suture lines are similar as for creating the lateral tunnel in TCPC we postulated that our technique for creating the intercaval tunnel without prosthetic material might prevent atrial flutter.
  
  
  METHODS
  All the children that qualified for a TCPC were included. Whenever possible our operative technique was applied. In the other cases a semi-prosthetic conduit was used for creating the intercaval tunnel. Of 47 consecutive patients 30 (64%) had a tunnel of right auricle tissue, 12 (26%) had a tunnel of prosthetic material. Five patients did not need an intercaval tunnel and were omitted in this study. Only surviving patients were included in this study. Patients that needed more atrial surgery then necessary for TCPC were also omitted. Postoperative ECG's and Holter monitorings were studied.
  
  
  RESULTS
  Overall mortality was 7 of 47 patients (14.9% 70% CL 9.4-22.2%). There was no mortality due to rhythm disturbances. Atrial flutter occurred in 3 of 31 included patients (9.7, 70% CL 4.3-18.5%). In the right auricle group 1 of 22 patients (4.5, 70% CL 0.6-14.6%) had atrial flutter compared to 2 of 9 patients (22.2, 70% CL 7.5-45.0%) in the prosthesis group (P=0.13).
  
  
  CONCLUSIONS
  The use of the right auricular technique for creating the intercaval tunnel TCPC is applicable in the majority of patients qualifying for a TCPC. Mortality and morbidity are equal comparing the two techniques. However, markedly less atrial flutter occurs in the group where the right auricle was used as intercaval tunnel. Therefore, we recommend the use of our technique for total cavopulmonary connection.
authors.affiliation: Thoraxcentre, Academisch Ziekenhuis Groningen, The Netherlands. t.w.waterbolk@thorax.azg.nl
authors.forename: T W
authors.initials: TW
authors.lastname: Waterbolk
authors.forename: M T
authors.initials: MT
authors.lastname: Bink-Boelkens
authors.forename: N J
authors.initials: NJ
authors.lastname: Elzenga
authors.forename: G C
authors.initials: GC
authors.lastname: Beaufort-Krol
authors.forename: T
authors.initials: T
authors.lastname: Ebels
mesh_terms: D001282:Atrial Flutter / Q000453:epidemiology / Q000517:prevention & control*; D016022:Case-Control Studies; D002675:Child, Preschool; D018729:Fontan Procedure; D018610:Heart Bypass, Right / Q000379:methods*; D006330:Heart Defects, Congenital / Q000601:surgery*; D006801:Humans; D015994:Incidence