Acquired Right Atrial Appendage to Right Ventricle Accessory Pathway in A Lateral Tunnel Fontan Patient: Successful Ablation Via Transconduit Approach (original) (raw)
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The Annals of Thoracic Surgery, 2003
Arrhythmia operations may be extended to patients with failed ablation procedures or associated structural defects requiring surgical intervention. The purpose of this study is to review our experience with arrhythmia operations in 29 patients who did not have Fontan conversions after the introduction of catheter ablation. Between July 1992 and January 2002, 29 patients had operations for refractory atrial (n = 24) or ventricular (n = 5) arrhythmias. Mechanisms of arrhythmia included atrial reentry (n = 11), atrial fibrillation (n = 5), automatic atrial (n = 3), accessory connections (n = 6), atrioventricular nodal reentry (n = 2), and ventricular tachycardia (n = 5). Median age at operation was 12.3 years (range, 6 days to 45 years). Two patients had structurally normal hearts; the remaining 27 patients underwent concomitant repair of structural heart disease, including atrioventricular valve replacement or repair (n = 8), anatomy-specific repair of Ebstein's anomaly (n = 4), tetralogy of Fallot repair or revision (n = 4), atrial septal defect closure (n = 3), ventricular septal defect repair (n = 2), Mustard takedown with arterial switch (n = 2), initial Fontan (n = 2), right ventricle-to-pulmonary artery conduit revision (n = 2), Norwood procedure (n = 1), 1 ventricular repair for Uhl's anomaly (n = 1), Mustard baffle revision (n = 1), pulmonary valve replacement with aneurysm resection (n = 1), and aortic valve replacement with complex repair (n = 1). No patient developed heart block, and the surgical mortality rate was 7%. One patient died after Mustard takedown and arterial switch operation, and 1 neonate died after repair of severe Ebstein's anomaly. There was one late death after arterial switch conversion at another institution. Recurrent clinical supraventricular tachycardia was present in 2 patients (2 of 27, 7.4%) and 2 patients had new-onset tachycardias with different underlying mechanisms of arrhythmia at late follow-up (median follow-up 47 months). Successful surgical therapy of arrhythmias can be performed safely at the time of repair of complex congenital heart disease or in patients with failed catheter ablation procedures. Early consideration for single-stage therapy of arrhythmia and structural heart disease is indicated.
Catheter Ablation of Accessory Pathway in the Treatment of Pacemaker-Mediated Tachycardia
Pacing and Clinical Electrophysiology, 2012
Pacemaker-mediated tachycardia (PMT) remains a clinical problem in patients with dual-chamber pacemaker despite technological advances. The onset mechanism of this tachycardia is sensing of retrograde atrial activation after ventricular stimulation. Repeated retrograde conduction perpetuates tachycardia. Postventricular atrial refractory period prolongation has been used for prevention of PMT, but this is not the solution in all cases. We present a case with PMT where the retrograde limb is a left accessory pathway, which is treated with radiofrequency ablation successfully. (PACE 2012; 35:e74-e76)
Pacing and Clinical Electrophysiology, 2009
We report the case of a patient presenting with incessant monomorphic ventricular tachycardia resistant to antiarrhythmic drugs, and in whom usual percutaneous vascular or pericardial access to the left ventricle was hindered by mechanical aortic and mitral prosthetic valves. Because an epicardial location was suspected by electrocardiogram features and because access to the target area through the coronary sinus was not possible, we decided to perform a surgically based radiofrequency (RF) ablation. Catheter mapping of the epicardial surface through surgical left lateral thoracotomy in the operating room confirmed the epicardial location of the arrhythmogenic substrate and allowed successful RF ablation of the clinically incessant tachycardia. Combined surgical and electrophysiological approach should therefore be performed when RF ablation is needed in case of unadvisable, difficult, or failed nonsurgical percutaneous access. (PACE 2009; 32:556-560)
International Heart Journal, 2020
An 18-year-old male who had a past medical history of an intracardiac total cavopulmonary connection (TCPC) operation was referred to our hospital for radiofrequency catheter ablation (RFCA) of supraventricular tachycardia (SVT). Two types of SVTs were induced, and 3-dimensional (3D) maps were created using an ultra-high-density 3-dimensional mapping system (Rhythmia). The earliest atrial activation site (EAAS) of SVT 1 was at the superior part of the conduit, and the EAAS of SVT2 was at the inferior part of the single atrium (SA). The SVTs were terminated by energy deliveries to the EAAS from the conduit in SVT1 and from inside the single atrium in SVT2. Detailed maps of the SVTs were important to understand the mechanisms of the SVTs. The Rhythmia system was useful for the detailed mapping of complex arrhythmias. The use of Rhythmia in patients after a TCPC is difficult, because puncturing the TCPC conduit and proceeding and manipulating the Orion catheter via a narrow puncture hole are difficult. We were the first to succeed in ablating two atrial tachycardias (ATs) originating from the inside and outside of the conduit after a TCPC operation by using an ultrahigh-density 3-dimensional mapping system.
Extracardiac Fontan operation for complex cardiac anomalies: Seven years' experience
The Journal of Thoracic and Cardiovascular Surgery, 1997
Between 1988 and 1995, 60 patients with complex cardiac anomalies underwent a total extracardiac cavopulmonary connection, a combination of a bidirectional cavopulmonary anastomosis with an extracardiac conduit interposition between the inferior vena eava and pulmonary arteries, except in one patient in whom direct anastomosis was possible. In 40 patients the total extracardiac cavopu!monary connection followed preliminary bidirectional cavopulmonary anastomosis, associated with a modified Damus-Kaye-Stansel anastomosis in 16. The conduits were construtted of Dacron fabric (n = 34), homografts in = 3), and polytetrafluoroethylene (n = 22). Results: Total early failure rate was 15% (n = 9). Six patients died, and three more had conduit takedown owing to pulmonary artery stenosis and hypoplasia (n = 2) and severe atrioventricular valve regurgitation (n = 1). Two other patients required anastomosis revision owing to stricture. In a mean follow-up of 48 months (6 to 86 monthe) there were no late deaths (actuarial 5-year survival 88%-4%); 52 of 54 patients are in New York Heart Association class I or II. Two patients required pulmonary artery balloon dilation or stent implantation, or both, after total extracardiac cavopulmonary connection. Late tachyarrhythmias were detected in four of 54 patients: two had sick sinus syndrome with flutter necessitating a pacemaker implantation and two had recurrent flutter lactuarial 5-year arrhythmia-free rate 92%-4%). Conduit pateney was evaluated by serial magnetic resonance imaging studies. Preliminary data showed a 17.8%-7.6% mean reduction in conduit internal diameter during the first 6 months after total extraeardiac cavopulmonary eonnection, with no progression over the next 5 years. Conclusion: These results demonstrate that the total extracardiac cavopulmonary connection provides good early and midterm results and may reduce the prevalence of late arrhythmias in patients undergoing the Fontan operation.
Journal of Cardiovascular Electrophysiology, 1998
Accessory AV Connection Between RAA and RV. A 24-year-old woman had experienced frequent attacks of orthodromic AV reciprocating tachycardia. The polarity of the delta waves suggested a right anterior or anterolateral accessory pathway. After ahlation at the tricuspid annulus was unsuccessful, earliest retrograde atrial activation was recorded on the floor of the right atrial appendage, 2 cm ahove the tricuspid ring. Application of radiofrequency energy at this site aholished accessory pathway conduction. This unusual accessory pathway, located hetween the floor of the right atrial appendage and the right ventricle, was amenable to radiofrequency catheter ahlation from within the right atrial appendage.
Arrhythmias after Fontan operation: comparison of lateral tunnel and extracardiac conduit
Journal of Electrocardiology, 2008
Background: Arrhythmias are frequent causes of morbidity and mortality in patients with single ventricle physiology after Fontan operation. The aim of this study was to evaluate which type of Fontan procedure-lateral tunnel (LT) or extracardiac conduit (EC)-provides superior outcomes related to the problem of early postoperative and 1-year follow-up arrhythmias. Methods: We retrospectively analyzed the incidence, types, and duration of rhythm disorders in 101 consecutive patients who received either LT (n = 60) or EC (n = 41) between April 1997 and March 2006 in Slovak Children's Cardiac Center, Bratislava (Slovakia). Weight, age, sex, and the type of heart morphology did not differ significantly between the 2 groups. The rhythm was monitored and documented perioperatively and postoperatively with standard electrocardiogram (ECG) recording and continual ECG monitoring. Duration of extracorporeal circulation, duration of aortic crossclamp and hemodynamic variables were analyzed with respect to the development of early arrhythmias in both groups. Twenty-four-hour ECG Holter monitoring (DMS 300-7, Holterreader, Producer DMS, Nevada, USA) was used to detect arrhythmias at the 1-year follow-up. Results: Early postoperative rhythm abnormalities were identified in 31 patients (52%) who underwent LT and in 22 patients (54%) who underwent EC. The most frequent type of rhythm disturbance was junctional rhythm in both groups. The bivariate analysis revealed that there was no significant difference in the incidence, type, or duration of early onset arrhythmias between the 2 groups. Although, there was no significant difference in the duration of arrhythmia since the admission form the operating room. The need of aortic crossclamp was significantly lower in EC group (P b .001). However, this did not correlate with lower incidence of early onset arrhythmias with EC modification. At the 1-year follow-up, the prevalence of arrhythmias was similar in both groups. Conclusions: Extracardiac conduit as compared with LT does not provide superior outcomes related to the problem of early and 1-year onset arrhythmias. Other factors than the risk of early postoperative and early follow-up arrhythmias should be considered in surgical preference of modification strategy.