Author + information
- Received July 25, 2018
- Revision received August 29, 2018
- Accepted September 6, 2018
- Published online January 21, 2019.
- aAssistance Publique–Hôpitaux de Paris, Groupe Hospitalier Pitié-Salpêtrière, Institut de Cardiologie, Paris, France
- bAssistance Publique–Hôpitaux de Paris, Cardiology Department, European Hospital Georges Pompidou, Paris, France
- ↵∗Address for correspondence:
Dr. Mikael Laredo, Assistance Publique-Hôpitaux de Paris, Groupe Hospitalier Pitié-Salpêtrière, Institut de Cardiologie, Unité de Rythmologie, 47-83 Boulevard de l'Hôpital, Paris, Ile de France 75013, France.
- atrial switch
- congenital heart disease
- incisional scar
- intra-atrial re-entrant tachyarrhythmia
- Mustard operation
A 45-year-old man with dextro-transposition of the great arteries and previous Mustard operation was referred for catheter ablation of persistent intra-atrial re-entrant tachycardia (IART). After transbaffle puncture, bipolar voltage mapping showed an area of dense scar in the posterolateral pulmonary venous atrium (PVA) (Figure 1A). Electro-anatomical activation and entrainment mapping demonstrated a counterclockwise peritricuspid IART (Figure 1B). Linear ablation with irrigated radiofrequency between the tricuspid annulus and the posterolateral scar interrupted the arrhythmia with further noninducibility. Bidirectionnal block was easily demonstrated by pacing on both sides of the ablation line (Figure 1C). There was no IART recurrence during a follow-up of 7 months.
Among IART, the predominant atrial arrhythmias complicating the course of dextro-transposition of the great arteries several decades after the Senning and Mustard operation, peri-tricuspid re-entry is the most frequent form (1,2). In anatomically normal hearts, peritricuspid re-entry is treated by cavotricuspid isthmus (CTI) linear ablation, as CTI provides 2 anatomical conduction barriers at its extremities, namely the inferior vena cava and the tricuspid annulus. After an atrial switch operation, the CTI is transected by the baffle suture, partitioning the CTI into both sides of the baffle. Therefore CTI ablation is necessarily biatrial, crossing the suture line (3). Whereas high rates of acute procedural success are reported with biatrial CTI ablation, long-term IART recurrences are reported in 30% of patients and are mostly represented by peritricuspid re-entry recurrences and IART involving the incisional scar of the PVA posterolateral wall (4). In this case, we used an alternative to CTI ablation by creating a line of block between tricuspid annulus and the PVA posterolateral scar, which, in our experience, is always found in Mustard recipients. Consequently, the ablation occurred entirely in the PVA. This alternative technique might have the advantage to be performed afar from the suture line and to prevent future IART involving the PVA posterolateral wall.
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
All authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the JACC: Clinical Electrophysiology author instructions page.
- Received July 25, 2018.
- Revision received August 29, 2018.
- Accepted September 6, 2018.
- 2019 American College of Cardiology Foundation
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