Catheter ablation of macro-reentrant atrial tachycardia in adults with Ebstein anomaly: A narrative review

Figure 1. A: Presenting electrocardiogram. B: Transthoracic echocardiogram (TTE) apical 4-chamber view with severely enlarged right atrium due to atrialization of the right ventricle and apical displacement of the tricuspid valve septal leaflet (yellow line). C: TTE agitated saline bubble study showing interatrial right-to-left shunting. D: Transesophageal echocardiogram (TEE) mid-esophageal 4-chamber view at 45° showing no left atrial appendage thrombus. E: TEE mid-esophageal 4-chamber view at 32° showing the apical displacement of the tricuspid valve septal leaflet of 18 mm from the anterior mitral valve (yellow line). F: TEE mid-esophageal 4-chamber view at 0° showing severe low-velocity tricuspid regurgitation jet by color-flow Doppler secondary to poor tricuspid valve coaptation that is apically displaced. G: TEE mid-esophageal at 89° showing right-to-left shunting through a patent foramen ovale by color-flow Doppler. EV = Eustachian valve; LA = left atrium; LV = left ventricle; MV = mitral valve; PFO = patent foramen ovale; RA = right atrium; RV = right ventricle; TR = tricuspid regurgitation; TV = tricuspid valve.

Figure 2. Right ventricular angiogram performed antegrade using pigtail catheter (anterior-posterior projection). The tricuspid valve leaflets are apically displaced resulting in an atrialized and a functional portion of the right ventricle. AV = atrioventricular; RA = right atrium; RV = right ventricle; TV = tricuspid valve.

Figure 3. Activation maps, containing 12632 points, accounted for 310 ms of the 320 ms cycle length. A: Counterclockwise typical atrial flutter (modified left anterior oblique projection). B: Cavotricupsid isthmus ablation with the primary line measuring 6.8 cm. (left anterior oblique caudal projection).

Figure 4. A: Post-ablation bipolar voltage maps in the right anterior oblique (left) and left anterior oblique caudal (right) projections. Thresholds were < 0.5 mV for diseased tissue and < 0.2 mV for dense scar. B: Post-ablation electrocardiogram.

Figure 5. Literature flow diagram. ACHD = adult congenital heart disease; MeSH = Medical Subject Headings.