Circulation. 2007;116:e315-e316
doi: 10.1161/CIRCULATIONAHA.107.716795
(Circulation. 2007;116:e315-e316.)
© 2007 American Heart Association, Inc.
Images in Cardiovascular Medicine |
Ablation of Atrial Flutter in a Patient With Mustard Procedure Using Integration of Real-Time Electroanatomical Mapping With 3-Dimensional Computed Tomographic Imaging
Arash Aryana, MD;
Richard R. Liberthson, MD;
E. Kevin Heist, MD, PhD;
Andre d’Avila, MD;
Ravi Mandapati, MD;
Ricardo C. Cury, MD;
Jeremy N. Ruskin, MD;
Moussa C. Mansour, MD
From the Cardiac Arrhythmia Service (A.A., E.K.H., A.d., J.N.R., M.C.M.), the Cardiology Division (R.R.L.), and the Department of Radiology (R.C.C.), Massachusetts General Hospital and Harvard Medical School, Boston, Mass; and the Department of Pediatrics (R.M.), Loma Linda University Medical Center, Loma Linda, Calif.
Correspondence to Dr Moussa C. Mansour, Cardiac Arrhythmia Service, Massachusetts General Hospital, GRB 109, 55 Fruit St, Boston, MA 02114. E-mail mmansour{at}partners.org
A 24-year-old woman with a history of surgical palliation of d-transposition of the great arteries, a systemic ejection fraction of 66%, and symptomatic atrial flutter with rapid ventricular response was referred for an electrophysiological study and ablation procedure. At 6 months of age, she had undergone a Mustard (atrial switch) procedure, whereby a "baffle" was surgically constructed within her atria to direct systemic venous blood across the mitral valve into the left ventricle (systemic venous ventricle) and the pulmonary artery, and pulmonary venous blood across the tricuspid valve into the right ventricle (pulmonary venous ventricle) and the aorta. Her ECG, which shows atrial flutter with a ventricular rate of 262 beats per minute with 1:1 atrioventricular conduction, is illustrated in Figure 1.
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Figure 1. Patient’s ECG shows atrial flutter with 1:1 atrioventricular conduction with a ventricular rate of 262 beats per minute.
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The procedure was performed under the guidance of the CARTO-MERGE electroanatomical mapping system (Biosense Webster, Inc., Diamond Bar, Calif.). After creation of a 3-dimensional anatomic construct from a high-resolution contrast-enhanced cardiac computed tomography, the cardiac structures were segmented (Figure 2). Integration of the computed tomography images with real-time intraprocedural electroanatomical mapping was performed by registration of the corresponding anatomic points inside the aorta. The resulting image allowed virtual navigation of the ablation catheter inside 3-dimentionally accurate anatomic cardiac structures. After construction of the map, a recording catheter was placed in the venous baffle and another in the apex of the systemic venous ventricle (SVV). With rapid pacing from inside the baffle, an atrial flutter with a cycle length of 295 ms was inducible. A mapping catheter was advanced via the aorta and the pulmonary venous ventricle via femoral arterial access to the pulmonary venous atrium (PVA) in a retrograde fashion (Figure 2). Entrainment mapping localized the tachycardia circuit to the tricuspid annulus (TA), an isthmus that spans the floor of the PVA and also the adjacent region inside the baffle (Figure 3). Multiple radiofrequency applications were delivered to the floor of the PVA near the TA, which resulted in progressive prolongation of the tachycardia cycle length without termination. However, after delivery of additional radiofrequency lesions to the floor of the baffle in an area adjacent to the TA isthmus and the PVA (Figure 3), the arrhythmia was successfully terminated. At the end of the procedure, atrial flutter was no longer inducible and the patient has remained free of arrhythmias during follow-up.
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Figure 2. An anterior (A) and a posterior (B) view of the 3-dimensional electroanatomical map of the heart and the great arteries, created with real-time integration with high-resolution contrast-enhanced cardiac computed tomography images. C, Cut-away anterior coronal view of the same electroanatomical map reveals a highly accurate anatomic construct of the venous baffle as well as the venae cavae and the interior of the PVA and the SVV. D, Right anterior oblique fluoroscopic view of the heart with all the catheters in position. AO indicates aorta; IVC, inferior vena cava; PA, pulmonary artery; PVA, pulmonary venous atrium; PVV, pulmonary venous (right) ventricle; SVC, superior vena cava; SVV, systemic venous (left) ventricle; VB, venous baffle; R1, recording catheter 1 (placed inside the baffle); R2, recording catheter 2 (placed in the apex of the SVV via the baffle); Apex, apex of SVV; MAP, mapping catheter (advanced to the floor of the PVA via the aorta and the PVV in a retrograde fashion); and TA, tricuspid annulus.
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Figure 3. A, External view of the integrated 3-dimensional cardiac electroanatomical map. B, Cut-away sagital internal view of the integrated 3-dimensional cardiac electroanatomical map. The white circles (arrow) denote sites where entrainment of the tachycardia resulted in exact postpacing return cycles. The red circles (arrow) represent sites of radiofrequency application. The middle panel shows atrial intracardiac ECGs of atrial flutter entrainment from the TA isthmus/floor of the PVA, with 3 paced beats followed by resumption of atrial flutter. Pacing at a cycle length of 275 ms (a) resulted in a postpacing interval of 295 ms (b), identical to the tachycardia cycle length (c), which demonstrated participation of these areas in the atrial flutter circuit. The lower panel illustrates atrial ECGs that demonstrated termination of atrial flutter during radiofrequency delivery (arrow) with restoration of sinus rhythm. For successful elimination of the atrial flutter, RF was delivered to the TA isthmus from inside the PVA along a region that stretched from the lateral wall to the TA, and also to the floor of the venous baffle.
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Intraatrial reentrant tachycardias are frequently seen in patients with surgically repaired d-transposition of the great arteries.1 Among these patients, TA isthmus–dependent reentry is most common and accounts for as many as 77%.2 Whereas in some patients catheter ablation that targets the TA isthmus via a retrograde approach and from inside the baffle can achieve favorable outcomes,2,3 in other patients it may also be necessary to target additional isthmus sites inside the PVA via a transbaffle/transseptal approach.4 Such procedures can pose a great technical challenge and require accurate identification of key anatomic locations and landmarks inside surgically modified structures. In this case, the image integration system remarkably enhanced the ablation of the atrial flutter in this patient in that it enabled us to visualize the ablation catheter in relation to the complex cardiac anatomy with great accuracy and fine detail. This approach may also prove highly useful in mapping and ablation of cardiac arrhythmias in patients with other types of complex congenital heart disease.
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Disclosures
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Dr Ruskin and Dr Mansour have received honoraria from and have
served on the Advisory Board or consulted for Biosense Webster
Inc. The other authors report no conflicts.
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References
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- Dong J, Zrenner B, Schreieck J, Schmitt C. Necessity for biatrial ablation to achieve bidirectional cavotricuspid isthmus conduction block in a patient following senning operation. J Cardiovasc Electrophysiol. 2004; 15: 945–949.[Medline]
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- Zrenner B, Dong J, Schreieck J, Ndrepepa G, Meisner H, Kaemmerer H, Schomig A, Hess J, Schmitt C. Delineation of intra-atrial reentrant tachycardia circuits after mustard operation for transposition of the great arteries using biatrial electroanatomic mapping and entrainment mapping. J Cardiovasc Electrophysiol. 2003; 14: 1302–1310.[CrossRef][Medline]
[Order article via Infotrieve]
- Collins KK, Love BA, Walsh EP, Saul JP, Epstein MR, Triedman JK. Location of acutely successful radiofrequency catheter ablation of intraatrial reentrant tachycardia in patients with congenital heart disease. Am J Cardiol. 2000; 86: 969–974.[CrossRef][Medline]
[Order article via Infotrieve]
- Perry JC, Boramanand NK, Ing FF. "Transseptal" technique through atrial baffles for 3-dimensional mapping and ablation of atrial tachycardia in patients with d-transposition of the great arteries. J Interv Card Electrophysiol. 2003; 9: 365–369.[CrossRef][Medline]
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Circulation 2007 116: 969.
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