Dysplasia of the tricuspid valve leading to recurrent atrial flutter and fibrillation: a case report

Figures

• 

• 

  Figure 1. Summary of the time course over 22 years, starting with a car accident at the age of 35 years. Lightning, electrical or medical cardioversion; y, age in years; mo, months; AFL, atrial flutter; AF, atrial fibrillation; cMR, cardiac magnetic resonance tomography; CTI, cavotricuspid isthmus; PVI, pulmonary vein isolation; ECG, electrocardiogram; EPS, electrophysiological study; TEE, transoesophageal echocardiography; TTE, transthoracic echocardiography; 3D-TEE, three-dimensional transoesophageal echocardiography; RA, right atrium; RV, right ventricle; TR, tricuspid regurgitation.

• 

  Figure 2. Electrocardiograms and electrophysiologic findings, registered during the first ablation. (A) The 12-lead electrocardiogram shows atrial flutter with a ventricular frequency of 70 bpm, normal axis, incomplete right bundle branch block, and normal repolarization. The atrial activation shows a sawtooth pattern with a cycle length of 270 ms, negative in inferior leads, with a slow downward slope followed by a fast upward slope, and a positive F-wave in V1. (B1) Intracardiac electrocardiogram of atrial flutter induced during cavotricuspid isthmus (CTI) ablation. The activation, registered by the halo catheter, is depicted as a yellow arrow and runs from the proximal to the distal part. The activation registered by the coronary sinus (CS)-catheter is depicted by the blue arrow and runs from the proximal to the distal part. The signals at the coronary sinus-catheter are partly not registered because of poor contact due to the dilatation of the right atrium and the coronary sinus. The ablation catheter (red point) is placed in the cavotricuspid isthmus. HIS, his bundle; RF, ablation catheter; Halo, 20-pole halo catheter positioned in the right atrium along the tricuspid ring. (B2)…

• 

  Figure 3. Cardiac magnetic resonance tomography in the end-diastolic phase (left) and in the end-systolic phase (right) shows significant dilatation of both the right atrium and right ventricle. Cine imaging is available in the supplementary material online. ra, right atrium; rv, right ventricle; la, left atrium; lv, left ventricle.

• 

  Figure 4. Tricuspid valve in the 3D-transoesophageal echocardiography (A) and in the 2D-transoesophageal echocardiography (B and C with colour Doppler) in the end-diastolic phase shows restriction of the septal leaflet, the regurgitant orifice (star), and the jet. Video clips are available in the supplementary material online. al, anterior leaflet; sl, septal leaflet; pl, posterior leaflet; ra, right atrium; rv, right ventricle.

• 

  Figure 5. Intraoperative picture of the tricuspid valve seen from the right atrium. The cleft (arrow) is held closed with tweezers and the clamp. al, anterior leaflet; sl, septal leaflet.