Subvalvular catheter ablation of the cavotricuspid isthmus in a patient with Ebstein's anomaly and tricuspid valve replacement

Figures

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  Figure 1. Representative CARTO map showing the ablation catheter advanced into the right ventricle and retroflexed below the tricuspid valve annulus. Atrial myocardium was not accessible using this approach.

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  Figure 2. Right anterior oblique view showing the relationship of the transseptal system to the porcine valve. The BRK needle is unsheathed and has punctured the valve ring, followed by contrast staining of the bioprosthesis (the valve struts are faintly outlined by contrast in this view).

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  Figure 3. Representative CARTO image of the cavotricuspid isthmus (CTI)–dependent intra-atrial reentrant tachycardia (IART) with additional lesions below the bioprosthetic valve from inside a newly created iatrogenic channel. The catheter shadow is shown at the final successful ablation site, which is distal to the earlier lesions. Large red marker indicates location of previous transient isthmus block. Yellow markers indicate location of ineffective lesions placed at the ventricular aspect of the valve. Upper insert: An intracardiac tracing demonstrates the pacing stimulus followed by sharp atrial and then far-field ventricular electrograms below the valve before ablation. Lower insert: There is cycle length prolongation and attenuation of the local electrogram prior to termination of the CTI-dependent IART during energy application below the bioprosthetic valve.