Atypical flutter following lung transplantation involving recipient-to-donor tissue connections

Figures

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  Figure 1. A: Imported 3-dimensional computed tomography scan reconstruction of the recipient left atrium and donor pulmonary veins with attached antral cuff; a clipping plane is used to show an internal view of the left atrial anastomosis site for the transplanted left lung. B: Fluoroscopy view (right anterior oblique projection) of the decapolar circular catheter in position just inside the left pulmonary vein (PV) donor cuff. The 10 poles of the Lasso are labeled as per standard catheter nomenclature. C: The figure-of-8 flutter circuit is demonstrated. The red arrows show wavefront propagation in a posterior-to-anterior direction within the PV donor cuff (near-field signals), with simultaneous superior and inferior routes being taken after wavefront entry to the cuff via a recipient-to-donor connection near Lasso pole number 6. The green arrows show wavefront propagation in an anterior-to-posterior direction, simultaneously traveling via superior and inferior routes around the outside of the anastomosis in recipient left atrial tissue, having exited the cuff via a second donor-to-recipient connection near Lasso pole number 2 (far-field signals). D: Surface electrocardiogram and…

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  Figure 2. A: Imported and merged 3-dimensional computed tomography scan reconstruction of the left atrium, with a clipping plane revealing an internal view of the left atrial anastomosis for the left lung graft. The yellow asterisk marks the site where entrainment pacing from the ablation catheter was performed during the maneuver shown in panel C. Aqua markers denote some of the sites where entrainment pacing was performed. Red and pink markers denote ablation sites, as further described in the text and in Figure 3 (of note, ablation had not yet been performed at the time of the entrainment maneuver demonstrated in this figure). B: Fluoroscopy view (right anterior oblique projection) of the decapolar circular catheter in position just inside the left pulmonary vein donor cuff. The 10 poles of the Lasso are labeled as per standard catheter nomenclature. The yellow asterisk marks the site where entrainment pacing from the ablation catheter was performed during the maneuver shown in panel C. C: During the clinical atypical atrial flutter, an entrainment maneuver is performed from the ablation catheter, which was positioned just outside the posterior recipient-to-donor electrical connection…

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  Figure 3. A: Surface electrocardiogram and intracardiac electrograms, recorded at a sweep speed of 50 mm/second, during radiofrequency ablation at the site marked in panel B. When radiofrequency energy is applied near Lasso 6, representing the electrical entry site where the flutter circuit traversed from recipient left atrium into donor pulmonary vein (PV) antral cuff, the tachycardia terminated (red asterisk). Note that the far-field electrograms from the native left atrial portion of the figure-of-8 circuit were inscribed (green arrows in Figure 1), but the tachycardia terminates before the near-field electrograms inside the donor cuff were inscribed (red arrows in Figure 1), consistent with termination at the posterior entry site electrical connection. With return of the first sinus beat after tachycardia termination, there is reversal of activation inside the PV cuff (red arrows), now with earliest cuff activation near Lasso electrodes 1 and 2, which previously served as the exit site during tachycardia. B: Imported and merged 3-dimensional computed tomography scan reconstruction of the left atrium, with a clipping plane revealing an internal view of the left atrial anastomosis for…