Atrial fibrillation originating from recipient left atrium after an orthotopic heart transplantation

Figures

• 

  Figure 1. Electrocardiogram showing irregular narrow complex tachycardia with variable rate of 130–150 beats per minute with a single dominant P-wave morphology (positive in lead V1 and negative in leads II, III, and aVF) with a relatively fixed PR interval of 130 ms.

• 

  Figure 2. Electroanatomic mapping of the left atrium (LA). A: Right posterior oblique orientation with ablation catheter in the anterior portion of the LA (donor LA) demonstrating an irregular but organized atrial tachycardia (similar to the coronary sinus catheter recordings). B: Posterior-anterior orientation with ablation catheter in the recipient atrium and pulmonary veins demonstrating high-frequency irregular atrial activity, with variable cycle length ranging between 180 and 260 ms, consistent with atrial fibrillation, with the highest-frequency atrial activity recorded near the right pulmonary veins.

• 

  Figure 3. Electroanatomic mapping of the left atrium (LA) in posterior-anterior orientation after restoration of sinus rhythm. A: Ablation catheter in the posterior wall (recipient LA) and coronary sinus (CS) catheter in donor CS; notice presence of bidirectional conduction between recipient and donor. B: Mapping of the posterior LA wall was performed using a 20-pole circular catheter (Lasso NAV catheter, Biosense Webster, Inc, Diamond Bar, CA) to identify the sites of conduction breakthrough. The earliest sites of conduction breakthrough (poles 9–10 and 19–20) were along the area just inferior-posterior to the right inferior pulmonary vein. C: Radiofrequency ablation at sites (9–10 and 19–20) resulted in complete isolation (entrance and exit block) of the recipient LA.