Volume 4, Issue 1, Pages (January 2007)

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Presentation transcript:

Volume 4, Issue 1, Pages 32-36 (January 2007) Right septal macroreentrant tachycardia late after mitral valve repair: Importance of surgical access approach Kurt C. Roberts-Thomson, MBBS, FRACP, Jonathan M. Kalman, MBBS, PhD, FACC Heart Rhythm Volume 4, Issue 1, Pages 32-36 (January 2007) DOI: 10.1016/j.hrthm.2006.09.032 Copyright © 2007 Heart Rhythm Society Terms and Conditions

Figure 1 A: Twelve-lead ECG from patient 1. B: A left lateral view of a biatrial electroanatomic (CARTO) activation map. Note the small area of scarring on the septum at the site of the transseptal incision. Scar was defined as areas with bipolar voltage <0.05 mV. Entrainment and activation mapping demonstrated a reentrant circuit around the scar and a simultaneous circuit around the tricuspid annulus. Ablation was performed between the scar and the tricuspid annulus terminating the tachycardia (red dots). TA = tricuspid annulus; CS = coronary sinus; MA = mitral annulus; LUPV = left upper pulmonary vein; RUPV = right upper pulmonary vein. Heart Rhythm 2007 4, 32-36DOI: (10.1016/j.hrthm.2006.09.032) Copyright © 2007 Heart Rhythm Society Terms and Conditions

Figure 2 A: Twelve-lead ECG from patient 2. Note the P wave morphology similar to patient 1. B: Electroanatomic map of the tachycardia showing a circuit around the septal scar and a simultaneous clockwise circuit around the tricuspid annulus. Entrainment mapping confirmed sites around the scar and the tricuspid annulus to be in the circuit. Ablation was performed between the scar and the superior tricuspid annulus (red dots). White dots indicate fractionated signals; blue dots indicate double potentials. TA = tricuspid annulus; SVC = superior vena cava; CS = coronary sinus. Heart Rhythm 2007 4, 32-36DOI: (10.1016/j.hrthm.2006.09.032) Copyright © 2007 Heart Rhythm Society Terms and Conditions

Figure 3 Electroanatomic map from patient 2. Shown is entrainment from five different sites; three sites around the tricuspid annulus and two sites around the septal scar (one between the scar and the tricuspid annulus and the other between the scar and the superior vena cava). Entrainment was performed at 310 ms, and the last beat of entrainment and the first two return cycles are shown. Note that all five sites are within the circuit. HBE = His bundle electrogram; CS d = distal coronary sinus; CS p = proximal coronary sinus; H 1,2 = distal Halo catheter, positioned at the low lateral TA; H 19,20 = proximal Halo catheter, positioned at the superior TA; Abl d = distal ablation electrode; Abl p = proximal ablation electrode. All numbers are in milliseconds. Heart Rhythm 2007 4, 32-36DOI: (10.1016/j.hrthm.2006.09.032) Copyright © 2007 Heart Rhythm Society Terms and Conditions

Figure 4 A: Twelve-lead ECG of patient 3. Note the flutter wave is negative in the inferior leads and biphasic (isoelectric/positive) in lead V1. B: In the right panel, a tilted left lateral view of a right atrial electroanatomic (CARTO) voltage map is shown. The voltage map demonstrates the region of septal scarring but also shows that surrounding tissue is very low voltage (red areas). Scar was defined as an area with bipolar voltage <0.05 mV, and low voltage in red indicates a voltage of <0.5 mV. Entrainment and activation mapping confirmed a reentrant circuit around the septal scar. There was a simultaneous counterclockwise circuit around the tricuspid annulus. Note the sites of radiofrequency ablation (red dots) between the septal scar and the superior tricuspid annulus, which terminated the tachycardia. TA = tricuspid annlus; IVC = inferior vena cava. Heart Rhythm 2007 4, 32-36DOI: (10.1016/j.hrthm.2006.09.032) Copyright © 2007 Heart Rhythm Society Terms and Conditions

Figure 5 Intracardiac recordings during successful radiofrequency ablation between the scar and the superior tricuspid annulus for patient 2. Shown are surface leads I, II, V1, and V6 along with intracardiac recordings from the ablation catheter (Abl), His bundle (HBE), coronary sinus (CS), and Halo catheter placed around the tricuspid annulus (TA). A: Low-amplitude ablation electrogram at the edge of the scar. Note that the activation pattern on the tricuspid annular catheter demonstrates a clockwise activation pattern (Halo 1,2 is low lateral TA and Halo 19,20 is high septal TA). B: Recordings during ablation with reduction in ablation electrogram amplitude and termination of the tachycardia on completion of the line. Heart Rhythm 2007 4, 32-36DOI: (10.1016/j.hrthm.2006.09.032) Copyright © 2007 Heart Rhythm Society Terms and Conditions

Figure 6 A superiorly tilted left anterior oblique view of a right atrial electroanatomic map from patient 2, during pacing from the lateral right atrium (star), after successful ablation. Note that during pacing, the last region of the right atrium activated is the septal side of the ablation line. This is demonstrated in the right panel, where the ablation catheter (Abl) is placed on the septal side of the line (circle), and its electrogram occurs after both the coronary sinus (CS) catheter and the atrial electrogram on the His catheter (HBE). H1,2: low lateral tricuspid annulus; H 19,20: high septal tricuspid annulus. Heart Rhythm 2007 4, 32-36DOI: (10.1016/j.hrthm.2006.09.032) Copyright © 2007 Heart Rhythm Society Terms and Conditions