Title [症例報告]One stage repair of concomitant Wolff-Parkinson-White syndrome and ventricular septal defect : A case report

Author(s)Kugai, Tadao; Koja, Kageharu; Kuniyoshi, Yukio; Iha,Kiyoshi; Akasaki, Mitsuru; Miyagi, Kazufumi; Shimoji,Mitsuyoshi; Kusaba, Akira; Misaki, Takuro

Citation 琉球医学会誌 = Ryukyu Medical Journal, 15(1): 41-43

Issue Date 1995

URL http://hdl.handle.net/20.500.12001/3260

Rights 琉球医学会

Ryu如Med. J‥ 15(1)41-43, 1995

One stage repair of concomitant Wolff-Parkinson-White syndromeand ventricular septal defect: A case report

Tadao Kugai*, Kageharu Koja*, **, Yukio Kuniyoshi*, Kiyoshi Iha*, Mitsuru Akasaki*,

K㌶ufumi Miyagi*, Mitsuyoshi Shimoji*, Akira Kusaba , ** and Takuro Misaki*

'Second Department of Surgeヮ, and **Research Center of Comprehensive Medicine,

Faculty of Medicine, University of the Ryu砂us, Okinawa, Japan

Toyama Medical and Pharmaceutical Universiか

(Received on March 3 , 1994, accepted on December 20, 1994)

ABSTRACT

We treated a　2.5 - year-old Japanese girl by one stage surgery for Wolff-Parkinson-

White (WPW)syndrome and associated with ventricular septal defect (VSD). VSD, 1 1. 5mm in size, was

corrected with a patch using expanded polytetra-fluoroethylene(E-PTFE)sheet through a

transpulmonary approach. The accessory atrioventricular pathway in type B was divided by

cryoablation through an endocardial approach. We suggest也at one stage operation must be used

for treating WPW syndrome and associated cardiac disorder, particularly, in infants and children as

morbidity and mortality are lower compared to those in staged radiofrequency ca也eter ablation

followed by surgical intervention. Ryukyu Med.J. , 15(1)41--43, 1995

Key words : One stage repair, WPW syndrome

INTRODUCTION

Concomitant heart disease with ventricular septal

defect (VSD) and Wolff-Parkinson-White syndrome (WPW

syndrome)in one patient is unusual". It is necessary for

VSD to be co汀ected simultaneously with surgical ablation of

accessory atrioventncular pathways. We report on a pa-

tient with VSD and WPW syndrome who was successfully

treated by one stage operation.

CASE REPORT

A 2. 5 - year-old Japanese girl was admitted to Ryukyu

University Hospital in February 1993. She was delivered

prematurely at 37 weeks of gestation weighing 2470g. The

delivery was spontaneous without any complications. She

was found to have a heart murmur with a suspected

diagnoisis of VSD on a mass examination at the age of one

month. At eight months of age, an electrocardiogram

revealed type B WPW pattern. At one year of age, type I

in VSD was detected by an echocardiogram and cardiac

catheterization, with a left to right shunting ratio of 33. 7 %蝣

There was no pulmonary hypertention (Fig. 1). Parox-

ysmal supraventncular tachycardia occurred during cardiac

cathetenzation. At 2 years of age, a mild aortic regurgita-

tion was detected by an echocardiogram (Fig. 2).

Laboratory examinations including arterial blood gas

analysis were within normal limits. The chest X-ray film

showed no pulmonary hypervascularity and no cardio-

41

megaly(CTR-43. 8%). Electrocardiogram showed a

sinus rhythm, a short P-R interval and delta waves.

Diagnosis was made as type B WPW pattern related to left

bundle branch block (Fig. 3).

Operative findings (Fig. 4)

The heart was approached through a median ster-

notomy. Maximum thrill was noted on the right ven-

tricular outflow tract. Electrophysiologic maps of the right

and left ventricles were made in sinus rhythm. Supraven-

tricular tachycardia was induced spontaneously, and epicar-

dial mapping was repeated with reference methods using

card type multielectrodegrids with 45 points on the left side

and 42 points on the right side. As the point of the earliest

endocardial activation was identified at the diaphragmatic

region (posterior wall)of the right ventricle, the antegrade

conductive accessory AV pathway was determined to be

located at near the posterior leaflet ring of the tncuspid

valve(Fig. 5) -

VSD with the size of ll. 5mm was located at the subaor-

tic region and was corrected with a patch using expanded

polytetra-fluoroethylene(E-PTFE)sheet through a

transpulmonary approach under cardiopulmonary

bypass (CPB). The division of the accessory pathways was

done through an endocardial approach. An incision and

dissection of the endocardium was extended circumferential-

ly along the tricuspid posterior leaflet annulus, 2mm away

from the hinge line, to ablate accessory pathway岳complete-

ly. After ablating accessory pathways, cryoablation was

applied three times for one minute using cryoprobe at -60℃

42One s亡age repair of WPW syndrome and VSD

Fig. 1 A right atriogram in the front projection (left) shows no evidence of

the atnahzed ventricle and the dilatated pulmonary artery. A left ven-

tnculogram in hepatoclavicular view (right) shows VSD shunt flow with left

to right shunting ratio 33. 1% (arrow).

Fig. 2 A preoperative electrocardiogram at 2 years of age shows VSD shunt

flow at the subaortic region(left), herniation of the right coronary

cusp (center) , and a mild aortic regurgitation (right).

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Fig. 3 A preoperative electrocardiogram(left)shows sinus rhythum, a short

P-R interval, delta waves and left bundle branch block. The findings of

left ventricular hypertrophy is not evident. A postoperative electrocar-

diogram (right: 6 P. 0. M. ) shows absence of a short P-R interval and delta

waves.

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Transpulmonary approach▼

MAjdmum thrill on RVOT

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Acces弧iry AV Pathway

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VSD(ll. 5m ; typel)　　　Closure with Gore-Tra sheel

Endocardia! appr<°adl

Endocard ia! Incision　　　　　°ablation (-60 1 )

Fig. 4 The operative procedure: The subaortic VSD in type I of ll. 5 mm in

size, was repaired with a patch using E-PTFE sheet through a trans-

pulmonary approach under cardiopulmonary bypass. The division of the

accessory pathway was done through endocardia] approach using the ap-

plication of cryoprobe for one minute at three times.

Fig. 5 The point of earliest endocardial activation was detected in the dia-

phragmatic region (posterior wall) of the right ventricle, and the location of

the antegrade conduction accessory atrioventricular pathway was determin-

ed approximately at the posterior leaflet ring of the tricuspid valve with

epicardial mapping.

Fig. 6 The division of accessory atrioventricular pathway was demonstrated

with an epicardial mapping on beat after weaning from cardiopulmonary

bypass.

Kugai, T.etal.

CC>2-　After weaning from CPB, the complete division of

the accessory pathway was demonstrated with epicardial

mapping on the heart beat(Fig. 6). The total CPB time

was　77　minutes with aortic cross clamping time of

45 minutes.

A postoperative electrocardiogram showed the absence

of a short P-R interval and delta waves, because of complete

division of the accessory pathways (Fig. 3).

The patient is now completely free from symptoms of

WPW syndrome and VSD.

DISCUSSION

The surgical treatment for WPW syndrome was original-

ly attempted by Sealy2) in 1968 and the success rate of the

surgical treatments has been markedly high with low mor-

bidity mortality in many Institutes3 41. Percutaneuos radio-

frequency catheter ablation of accessory pathways has

recently evolved as a promising technique in也e treatment of

WPW syndrome. With this technique, Calkins et aP¥

reported a 93% success in 56 cases, and Lesh etaP- a 89% sue-

cess of 109 accessory pathways in 100 cases. Jackman and col-

leagues71 also reported a 99%　success of 177 accessory

pathways in 166 cases. These results of radio-frequency

ablation procedures for WPW syndrome were similar to

those of the surgical ablation. Therefore, a staged catheter

ablation prior to carrying the surgery for concomitant struc-

tural heart disease including cardiac valve diseases or car-

diac anomalies was advocated, since surgery for concomi-

tant heart disease often places the patient at a risk of develop-

ing supraventricular tachycardia during the surgery.

Although the concept of ablating accessory pathways

without resorting to the standard cardiac surgery is attrac-

tive, the potential for long-term critical adverse effects of

radio-frequency catheter therapy is still unclear. Prolong-

ed radiation exposure requiring 1 0 to 14 hours for one session

of the catheter ablation, wm have adverse effects on patients,

especially infants and children. The catheter ablation

therapy is associated with substantial morbidity, in eluding

coronary occlusion and aortic valve injury, as compared to

those in surgical ablations. Even though radio- frequency

is said to be less traumatic, long-term adverse effects of

radio-frequency energy delivery on the surrounding tissues

including coronary artery adjacent to the site of ablation is

unclear. In addition, the safe application of radio-frequen-

cy catheter ablation technique is now approved only in

special Institutes, and should be limited to cases with WPW

syndrome without coexisting heart diseases.

43

We conclude that, in the treatment of infants and

children, wi也concomitant WPW syndrome and other struc-

tural heart disease, one stage surgical repair of accessory

pathways and an accompaning structural heart disease

would be preferable.

REFERENCES

1 ) Cox, J. L. : The status of surgery for cardiac arrythmi-

as. Circulation 71: 13 - 417, 1985.

2) Cobb, F. R., Blumenschein, S. D., Sealy, W. C.,

Boineau, J. P., Wagner, G. S., andWallace, A. G.:

Successful surgical interruption of the Bundle of Kent in

a patient with Wolff-Parkinson-White syndrome. Cir-culation 38: 1018 - 1029, 1968.

3) Guiraudon, G. M., Klein, G. J., Sharma, A. D.,

Jones, D. L. , and McLellan, D.G. : SurgeryforWPW

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