Successful atrial fibrillation ablation without pulmonary vein isolation utilizing focal impulse and rotor mapping in an atriopulmonary Fontan Madhukar.

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Successful atrial fibrillation ablation without pulmonary vein isolation utilizing focal impulse and rotor mapping in an atriopulmonary Fontan Madhukar Kollengode, MD, Jehu Mathew, MD, Elizabeth Yeung, MD, William H. Sauer, MD, FHRS, Duy Thai Nguyen, MD, FHRS HeartRhythm Case Reports Volume 4, Issue 6, Pages 241-246 (June 2018) DOI: 10.1016/j.hrcr.2018.02.009 Copyright © 2018 Heart Rhythm Society Terms and Conditions

Figure 1 A: Regular narrow-complex long RP tachycardia elicited during exercise study. B: Symptomatic irregularly irregular tachycardia without P waves consistent with atrial fibrillation was noted on event monitor. C: During isoproterenol infusion, triggers were noted with runs of intra-atrial reentrant tachycardia with earliest signals at the ablation catheter (yellow arrow). D: An array of catheters was utilized to appropriately investigate and ablate tachycardias. The ablation catheter is positioned at the border zone. Embolization coils are seen within the collateral vessel (red arrows). E: Voltage map of the right atrium/Fontan pathway revealed a dense strip of scar (red) within the inferolateral limb of the Fontan, continuous with the inferior vena cava, with a border zone between normal tissue and scar. ICE = intracardiac echocardiography; IVC = inferior vena cava; PA = posteroanterior; RAO = right anterior oblique; SVC = superior vena cava. HeartRhythm Case Reports 2018 4, 241-246DOI: (10.1016/j.hrcr.2018.02.009) Copyright © 2018 Heart Rhythm Society Terms and Conditions

Figure 2 A: Fontan angiography revealed a markedly dilated IVC and RA, with unobstructed Fontan pathway to branch pulmonary arteries. A large venoatrial collateral from the SVC to left atrium was seen (green arrow) and subsequently embolized. B: A 64-pole FIRM multipolar basket (blue arrow) was introduced into the Fontan. C, D: Electroanatomic mapping was performed to define any underlying electrophysiological abnormalities contributing to atrial fibrillation maintenance. The FIRM basket catheter is visualized within 3-dimensional high-density electroanatomic maps. A rotor (yellow area) was identified within the Fontan near the border zone. E: Raw unipolar electrograms collected from the FIRM basket catheter, which are then exported to a proprietary mapping system that determines physiologically plausible activation paths. F: FIRM-derived computational phase map depicting electrical propagation during atrial fibrillation, revealing a rotor (yellow arrows) and adjacent focal impulse (asterisks). AP = anteroposterior; FIRM = focal impulse and rotor mapping; IVC = inferior vena cava; PA = posteroanterior; RA = right atrium; RAO = right anterior oblique; SVC = superior vena cava. HeartRhythm Case Reports 2018 4, 241-246DOI: (10.1016/j.hrcr.2018.02.009) Copyright © 2018 Heart Rhythm Society Terms and Conditions

Figure 3 Representative electroanatomic map of the right atrium/Fontan pathway demonstrating the various identified pathologic triggers and mechanisms of maintenance of arrhythmia and subsequent sites of ablation. CTI = cavo-tricuspid isthmus; IART = intra-atrial reentrant tachycardia; IVC = inferior vena cava; RA = right atrium; RAO = right anterior oblique; SVC = superior vena cava. HeartRhythm Case Reports 2018 4, 241-246DOI: (10.1016/j.hrcr.2018.02.009) Copyright © 2018 Heart Rhythm Society Terms and Conditions