Endocardial wavefront propagation guiding atrioventricular nodal re-entrant tachycardia ablation after modified Fontan

Figures

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  Figure 1. A 27-year-old patient with hypoplastic left heart syndrome, interrupted inferior vena cava with azygous continuation, and bilateral superior vena cavae status post multiple surgical palliations, including Norwood procedure, left pulmonary artery stenting, left-sided bidirectional Glenn anastomosis, and implantation of conduit connecting hepatic venous confluence to the azygous vein. Transhepatic and transbaffle puncture was required for intracardiac access to perform 3-dimensional mapping and catheter ablation of the slow pathway to the atrioventricular (AV) node to treat atypical AV node re-entry tachycardia. AC = azygous continuation; HVC = hepatic venous confluence; LA = left atrium; LBDG = left bidirectional Glenn; LPA = left pulmonary artery; RA = right atrium; RBDG = right bidirectional Glenn; RPA = right pulmonary artery; RV = right ventricle; VC = Versacross (Boston Scientific, Marlborough, MA) catheter access.

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  Figure 2. A:Upper panel: 12-lead electrocardiogram demonstrating long-RP tachycardia in a 27-year-old post-Fontan patient. Retrograde P waves are inverted in leads II and aVF, and upright in V1 and V2. B:Lower panel: Surface electrocardiogram tracings and intracardiac electrograms demonstrating induction of supraventricular tachycardia with ventricular extrastimulus testing. ABLdis = distal ablation; ABLp = proximal ablation; TEP = transesophageal catheter.

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  Figure 3. Clipped snapshot (CARTO 3, 3-dimensional system, Biosense Webster, Diamond Bar, CA; right anterior oblique view) of propagation mapping showing wavefront collision during low right atrial rhythm in a post-Fontan patient. A: Wavefront collision in the triangle of Koch (thin light purple lines surrounding dark purple, see Supplemental Video 1). B: His bundle electrograms (yellow tags). C: Sites of brief RF ablation (covered green tag) and catheter positions during cryoablation anterior to the coronary sinus (D, mesh).