HeartRhythm Case Reports

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HeartRhythm Case Reports Atrial Fibrillation Ablation Without Pulmonary Vein Isolation in an Atrio-pulmonary Fontan Circulation John L. Fitzgerald, MBBS(Hons), Nicholas J. Collins, MBBS, James Leitch, MBBS, Eugene Downar, MD, Krishnakumar Nair, MD, Nicholas Jackson, MBBS HeartRhythm Case Reports DOI: 10.1016/j.hrcr.2019.07.008 Copyright © 2019 Heart Rhythm Society Terms and Conditions

Figure 1A A 12-lead ECG of the clinical arrhythmia Figure 1B, 1C RAO and LAO views of the Fontan circuit (light green). Aorta pink, atretic right ventricle red, systemic (and morphologically left) ventricle dark blue and the left atrium in light blue. The Damus-Kaye-Stansel connection (pulmonary artery to aorta) is seen in the LAO view. HeartRhythm Case Reports DOI: (10.1016/j.hrcr.2019.07.008) Copyright © 2019 Heart Rhythm Society Terms and Conditions

Figure 2A Atrial Fibrillation. Numbered electrode pairs on a pentaray catheter are labelled PR, with this catheter positioned over mostly healthy tissue on the posterior wall of the Fontan circuit. Numbered electrode pairs on a duodecapolar catheter are labelled DD with catheter orientation from proximal to distal up the anterior wall, along the roof and down the posterior wall of the Fontan circuit.Figure 2B A Posterior view of left atrial lesion set (red dots). Black dots mark complex fractionated electrograms with healthy voltage tissue shown in purple on this voltage map.Figure 2C An Anterior view of the Fontan circuit. Again showing healthy tissue in purple and regions of dense scar in red. Ablation to organise the AF was not needed anteriorly. Figure 2D Organisation of atrial fibrillation to IART during ablation. Map d is the distal ablation catheter electrode with ablation artefact seen. Electrograms marked DD 5,6 to 9,10 show disorganised atrial activity in atrial fibrillation reverting to organised sequential activation in IART. HeartRhythm Case Reports DOI: (10.1016/j.hrcr.2019.07.008) Copyright © 2019 Heart Rhythm Society Terms and Conditions

Figure 3A Right lateral view of the activation map showing the IART circuit (white circle with arrowheads). Complex fractionated electrograms in IART are marked with purple dots.Figure 3B Complex fractionated and mid-diastolic electrograms on the Pentaray catheter capturing the entire tachycardia cycle length. The red arrow indicates the electrogram where the first IART transitioned with ablation. Figure 3C Transition of first IART to a second IART. EGMs marked DD show duodecapolar catheter poles oriented with the proximal poles anteriorly, and the catheter pointing up the anterior wall, along the roof in an Antero-posterior direction with distal poles against the posterior wall of the Fontan circuit.Figure 3D Slowing and termination of second IART to sinus rhythm. HeartRhythm Case Reports DOI: (10.1016/j.hrcr.2019.07.008) Copyright © 2019 Heart Rhythm Society Terms and Conditions