Diagnostic multipolar electrode catheters were placed via the femoral vein into the RA and pulmonary ventricle (PV) ( Figure 2a,b). Thus, the ablation was performed utilizing CARTO-Sound merge of MRI, ICE and contact mapping provided by a 3.5 cm-tip ThermoCool (Biosense Webster, Inc., Diamond Bar, CA) ablation catheter. We prospectively anticipated challenges in catheter manipulation related to the atrial baffle anatomy based on his MRI, which incompletely characterized the physiologic venous or right atrium (RA) and revealed a very abnormal physiologic systemic or left atrium (LA). He was referred for catheter ablation.įigure 1: Patient's electrocardiogram showing atypical atrial flutter with 1∶1 atrioventricular conduction. He was managed on high-dose β blocker alone but had frequent recurrent breakthrough episodes of tachycardia associated with syncope. ![]() Unfortunately, he developed acute pulmonary toxicity related to the amiodarone. Management for his tachycardia included a β blocker and amiodarone. Evaluation included a contrast-enhanced MRI, which showed markedly misshapen and enlarged atrial baffles without leak or stenosis and a hypertrophied systemic ventricle with an ejection fraction estimated at 30%. A cardioversion was required to terminate the arrhythmia. Adenosine infusion revealed atrial flutter, confirming the clinical tachycardia was atrial flutter with 1:1 atrioventricular conduction ( Figure 1). This was associated with palpitations, chest discomfort, shortness of breath, hypotension, and the sensation of “a near-death experience”. He had done well, until the development of his first episode of narrow QRS tachycardia at a cycle length of 260 ms. The patient is a 31-year-old man with D-transposition of the great arteries, status post Blalock-Hanlon septectomy and Mustard procedure performed at age 3. 5 Here, we present a patient with D-TGA, systemic ventricular failure, severely deformed atrial baffle, and recurrent near-syncope related to sustained narrow complex tachycardia. This allows for not only a real-time 3D image acquisition but can also provide needed anatomic details for certain ablations. More recently, a new imaging addition is the use of two-dimensional (2D) intracardiac echocardiograpy (ICE) image slices, which are manually reconstructed into three-dimensional (3D) images and merged with preprocedure cardiac CT or MRI. 4 Therefore, SVT suppression for individuals with atrial redirective reconstructive surgery with systemic ventricular failure is of extreme importance.Īdvanced cardiac imaging, such as computed tomography (CT) and cardiac magnetic resonance imaging (MRI) merged with electroanatomic mapping, has been utilized to assist with complex ablations. Data from implantable cardioverter-defibrillator (ICD) registries of D-TGA patients indicate that SVT often coexists or precipitates malignant ventricular arrhythmias leading to ICD therapy or SCD. Additionally, supraventricular tachycardia (SVT) is considered to be a risk factor for the development of ventricular arrhythmias and SCD. 1– 3 Etiology of SCD has been attributed to tachyarrhythmias rather than bradyarrhythmias, given the observation that patients with D-TGA and pacemakers are not protected from SCD. By the time individuals reach the second to fourth decade of life, systemic ventricular failure, baffle leaks or obstruction, atrial arrhythmias, ventricular arrhythmias, and sudden cardiac death (SCD) can result. Individuals with complete transposition of the great arteries (D-TGA) following atrial redirective reconstructive surgery, such as a Mustard or Senning baffle, can develop a multitude of late complications. Eckhardt, MD, Division of Cardiovascular Medicine, University of Wisconsin School of Medicine and Public Health, 600 Highland Ave, H6/343 CSC, Madison, WI 53792. Manuscript received August 26, 2010, final version accepted September 20, 2010.Īddress correspondence to: Lee L. The authors report no conflicts of interest for the published content. D-TGA, catheter ablation, atrial flutter, ultrasound-guided imaging, intracardiac electroanatomic mapping. ![]() ECKHARDT, MD and CESAR ALBERTE, MDĭivision of Cardiovascular Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI Catheter Ablation for D-TGA Related Atrial Flutter Using Intracardiac Guided Echocardiography
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