Successful catheter ablation using real-time ultrasound-assisted 3-D electroanatomical mapping system for atrioventricular accessory pathway in a 1-year-old.

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Successful catheter ablation using real-time ultrasound-assisted 3-D electroanatomical mapping system for atrioventricular accessory pathway in a 1-year-old girl with criss- cross heart Shigeo Watanabe, MD, Yoko Yoshida, MD, Tsugutoshi Suzuki, MD, PhD, Yoshihide Nakamura, MD HeartRhythm Case Reports Volume 2, Issue 4, Pages 351-355 (July 2016) DOI: 10.1016/j.hrcr.2016.04.002 Copyright © 2016 Heart Rhythm Society Terms and Conditions

Figure 1 A: Surface 12-lead electrocardiogram demonstrating normal sinus rhythm without delta waves. The heart rate was 115 beats/minute. B: Surface 12-lead electrocardiogram demonstrating narrow QRS complex and a regular RR tachycardia. The heart rate was 254 beats/minute. Small retrograde P waves followed after each QRS complex. Orthodromic atrioventricular reentrant tachycardia with a concealed accessory pathway was suspected. HeartRhythm Case Reports 2016 2, 351-355DOI: (10.1016/j.hrcr.2016.04.002) Copyright © 2016 Heart Rhythm Society Terms and Conditions

Figure 2 A: 3-D enhanced computed tomography (CT) revealed the structure of the heart in the present case. The right atrium (RA) drained through the mitral valve to the posterior morphologic left ventricle (LV). The left atrium (LA), lying posterosuperior and to the left of the RA, drained through the tricuspid valve to the anterior morphologic right ventricle (RV), from which the aorta (Ao) originated anteriorly. The tricuspid valve opened anteriorly, and the mitral valve opened to the left. The ventricular septum was oriented vertically. B: Endocardial contours of the aortic root, RV, LV, and RA were traced (green line) using esophageal SOUNDSTAR. Cross-sectional images, including the mitral annulus (deep blue tag), were obtained. CT images were integrated into the CARTOSOUND system. C: Echocardiography provided by esophageal SOUNDSTAR demonstrated that the tip of the ablation catheter was located just at the tricuspid annulus. AP = anteroposterior view; LAO = left anterior oblique view; RAO = right anterior oblique view. HeartRhythm Case Reports 2016 2, 351-355DOI: (10.1016/j.hrcr.2016.04.002) Copyright © 2016 Heart Rhythm Society Terms and Conditions

Figure 3 A: The CARTOSOUND system demonstrated various tags created by electroanatomical mapping–intracardiac echocardiography and 3-D computed tomography images. The His bundle potential was located at the anterior “right-sided” mitral annulus at the junction of the mitral and tricuspid annuli. The successful ablation site was located at the superior “left-sided” tricuspid annulus at 20 mm distance from the His potential. The mitral annulus diameter was 19 mm, and the tricuspid annulus diameter was 14 mm. AP = anteroposterior view; LAO = left anterior oblique view; LV = left ventricle; RV = right ventricle. B: During sinus rhythm, intracardiac electrogram demonstrated dull His bundle potential (arrow). C: During orthodromic atrioventricular reentrant tachycardia, a single application of radiofrequency current for the earliest atrial activation site immediately (1.6 seconds after application) terminated tachycardia. HeartRhythm Case Reports 2016 2, 351-355DOI: (10.1016/j.hrcr.2016.04.002) Copyright © 2016 Heart Rhythm Society Terms and Conditions