Electrophysiology and surgery intertwined in complex treatment of Ebstein’s anomaly in childhood

Figures

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  Figure 1. Electrophysiological study. A: Twelve-lead electrocardiogram (ECG) prior to ablation. B: Orthodromic atrioventricular reentrant tachycardia with right bundle branch block QRS morphology and QRS complex duration of 120 ms. C: Local electrograms at successful ablation site of the right posteroseptal accessory pathway from the cryo-catheter (FRZ dist and uni) with ventricular signal coinciding with delta wave onset. The strictly negative ventricular signal from the ablation catheter tip (FRZ uni) is in favor of correct placement at the ventricular insertion site of the posteroseptal pathway. D: Local electrograms after posteroseptal pathway ablation (FRZ dist) with clear division of the atrial and ventricular electrogram at the ablation site. E: Twelve-lead ECG showing different QRS morphology after posteroseptal pathway ablation with a delta wave evident especially in leads I and V4. F: Local electrograms at the site of the second unsuccessfully ablated right posterior pathway (FRZ dist) with ventricular signal clearly preceding delta wave onset. G: Three-dimensional electroanatomical map of the earliest ventricular activation on the tricuspid annulus (delineated by the black line)…

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  Figure 2. A: Twelve-lead electrocardiogram after right ventricular cardiac resynchronization therapy (RV-CRT) showing narrow QRS complex (=70 ms) with absence of right bundle branch block. B: Longitudinal strain imaging of the right ventricle during baseline rhythm with right bundle branch block. Significant RV mechanical dyssynchrony is evident with early septal contraction (green arrow) accompanied by RV free wall pre-stretch (yellow arrow) followed by late free wall contraction (red arrow) and septal rebound stretch (orange arrow). Peak basal RV free wall contraction occurs 57 ms after pulmonary valve closure (PVC; green line), thus not contributing to RV ejection. RV septal-to–free wall mechanical delay is 97 ms. C: During RV-CRT RV dyssynchrony is abolished with synchronous contraction of the septum and RV free wall. Peak basal RV free contraction occurs almost simultaneously with pulmonary valve closure. RV contraction efficiency is restored.