Clinical problem solving: Maneuvering around a narrow complex tachycardia in a patient with Mustard repair for transposition of the great arteries Nicholas.

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Presentation transcript:

Clinical problem solving: Maneuvering around a narrow complex tachycardia in a patient with Mustard repair for transposition of the great arteries Nicholas Jackson, MBBS, Malcolm Barlow, MBBS, Mehrdad Emami, MD, Krishnakumar Nair, MD, Nicholas Collins, MBBS HeartRhythm Case Reports Volume 2, Issue 6, Pages 536-539 (November 2016) DOI: 10.1016/j.hrcr.2016.06.003 Copyright © 2016 Heart Rhythm Society Terms and Conditions

Figure 1 A: Fluoroscopic image in right anterior oblique that shows 2 pacing leads enter the heart through the superior vena cava baffle. The atrial lead sits in the systemic venous atrial appendage and the ventricular lead sits in the subpulmonic left ventricle. Decapolar and quadripolar electrophysiology catheters sit adjacent to these leads. B: Onset of a tachycardia episode from the patient’s permanent pacemaker. The atrial and ventricular bipolar electrograms are shown along with the marker channel. C: Electrocardiogram (ECG) in sinus rhythm with right axis deviation and evidence of right ventricular hypertrophy (typical of a patient post Mustard repair). There is also a relatively short PR interval (130 ms) and a slurred onset to the QRS, which raises the suspicion of pre-excitation. D: Twelve surface ECG leads above atrial (CS 1-10) and ventricular (right ventricular apical) electrograms where an atrial extrastimulus initiates tachycardia. HeartRhythm Case Reports 2016 2, 536-539DOI: (10.1016/j.hrcr.2016.06.003) Copyright © 2016 Heart Rhythm Society Terms and Conditions

Figure 2 A: Overdrive pacing from the left ventricular apex (sub-pulmonic ventricle) during tachycardia. The decapolar catheter is positioned as shown in Figure 1A (as is the case in all panels). B: Variation in the VA timing during tachycardia when the QRS morphology changes from left bundle branch block to narrow complex to right bundle branch block morphologies (V denotes ventricular electrograms and A denotes atrial electrograms on the distal ablation catheter). C: Entrainment of tachycardia from the ablation catheter, which is sitting at 2 o’clock on the mitral annulus. The tachycardia cycle length and post-pacing intervals are shown. D: Electroanatomic map of the mitral annulus using the CARTO mapping system, where the timing of atrial activation was annotated during tachycardia. Earliest activation is shown in red and ablation lesions are shown as red dots over this point of earliest atrial activation (the accessory pathway location). HeartRhythm Case Reports 2016 2, 536-539DOI: (10.1016/j.hrcr.2016.06.003) Copyright © 2016 Heart Rhythm Society Terms and Conditions