Pediatric and Congenital EPAtrial tachycardia eliminated at the ventricular side in patients with congenitally corrected transposition of the great arteries: Electrophysiological findings and anatomical concerns
Introduction
Atrial tachycardia (AT) is a common complication and significant source of morbidity of adult congenital heart disease, and catheter ablation has been established as an effective approach for management.1 Congenitally corrected transposition of the great arteries (cc-TGA) is a rare condition featured by atrioventricular discordance coexisting with ventriculoarterial discordance, the prevalence of which in combination with dextro-transposition of great arteries is estimated to be 0.04 cases per 1000 adults.2 Concomitant with these discordances, the pulmonary outflow tract (POT), rather than the aortic root in normal hearts, is located deeply between the 2 atria (Figure 1). Unlike other adult congenital heart diseases, substrate for intra-atrial reentry caused by surgical scar or abnormal anatomical barriers is not prominent in cc-TGA. We have encountered a special type of cc-TGA AT, with the earliest atrial activation site at the anterior septum of the atria but refractory to ablation at this site. However, much earlier activation could be recorded from the POT where AT could be successfully ablated. This study aims to describe the anatomical and electrophysiological characteristics of this type of cc-TGA AT.
Section snippets
Study population
Between October 2011 and September 2018, 6 patients with cc-TGA undergoing mapping and ablation of ATs were analyzed. In 1 patient, AT originating only from the inferior left atrium (LA) was documented. All other 5 patients had AT successfully ablated at the POT and were included in this study. The study complied with the Declaration of Helsinki, and the protocol was approved by the Institutional Review Board of Beijing Anzhen Hospital. Each participant provided their written informed consent
Basic characteristics
The main clinical and anatomical characteristics of the patients included in this study are summarized in Table 1. All these 5 patients with situs solitus–type cc-TGA (usual atrial arrangement). Ventricular septal defect existed in 2 patients (cases 1 and 4). The POT diameter was 26.2 (22.7–37.1) mm, and pulmonary stenosis was not observed in any of these patients. A single type of AT was documented in 3 patients, while 2 types of ATs were documented in 2 patients. The mechanisms of ATs other
Main findings
In patients with unrepaired cc-TGA of the situs solitus type, AT could arise from the POT, with intra-atrial activation begins at the anteroseptal area in the RA and the septal wall away from the annulus in the LA with a comparable LAT. In 5 of 6 patients in the present series, the EAS was recorded in the POT and ablation here could successfully eliminate the arrhythmia.
Anatomical basis
The situs solitus–type cc-TGA is a congenital malformation attributed to right looping of the heart tube and formation of a
Conclusion
AT arising adjacent to the POT is not an uncommon tachycardia in patients with situs solitus–type cc-TGA, featured by a diffuse initial activation pattern in the septal region of the atria and can be safely eliminated by ablation targeting the EAS in the POT.
References (7)
- et al.
2018 AHA/ACC Guideline for the Management of Adults With Congenital Heart Disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines
J Am Coll Cardiol
(2019) - et al.
An embryologic explanation for the corrected transposition of the great vessels: additional description of the main anatomic features of this malformation and its varieties
Am Heart J
(1959) - et al.
Atrial tachycardia arising adjacent to noncoronary aortic sinus: distinctive atrial activation patterns and anatomic insights
J Am Coll Cardiol
(2010)
Cited by (5)
Atrial tachycardia ablation from the pulmonic valve in a patient with congenitally corrected transposition of great arteries
2022, HeartRhythm Case ReportsCitation Excerpt :It could be explained by its anatomy that the junction between the pulmonary artery and atrium was located at the superior septal atrium (Figure 1G). Previous studies1,3 speculated that the tachycardia mechanism was microreentry, by observing the complex fractionated electrograms or the conduction delay between the double potentials. During the electrophysiological study in the present case, the clinical tachycardia could be reproducibly induced and terminated by atrial stimulation.
Atrial Tachycardia Ablation at the Pulmonic Valve in a Patient With Congenitally Corrected Transposition of Great Arteries
2021, JACC: Clinical ElectrophysiologyCitation Excerpt :And, as Dr Cheung and his colleagues emphasize, it is now well recognized that, in the normal heart, the substrate for para-Hisian arrhythmias can be ablated from the sinuses of the aortic root. As the authors also point out, at least 2 groups have described treatment of atrial tachycardias in patients with congenitally corrected transposition by ablating in the nonadjacent or leftward facing sinuses of the pulmonary trunk (6,7). This approach was also described by Roca-Luque et al (12).
Atrial flutter catheter ablation in adult congenital heart diseases
2021, Indian Pacing and Electrophysiology JournalCitation Excerpt :The chronic tricuspid valve regurgitation can result in progressive left atrial dilatation associated with the development of left atrial arrhythmias (Fig. 10 and (video 4) [46–48]. Lastly, as in patients with cc-TGA and situs solitus the pulmonary outflow tract, rather than the aortic root in normal hearts, is located deeply between the 2 atria, successful catheter ablation of atrial tachycardia has also been reported in pulmonary sinus [49]. The non-facing pulmonary sinus is in contact with the right atrium and the left-facing is in contact with the left atrium (Fig. 9).
Management for atrial arrhythmias in adults with complex congenital heart disease
2023, Expert Review of Cardiovascular Therapy
This work was supported by the National Key Research and Development Program of China (2017YFC0908803, 2017YFC1307800) and the National Natural Science Foundation of China (81770326).
Dr Ma has received honoraria for presentations from AstraZeneca, Bayer Healthcare, Boehringer Ingelheim, Bristol-Myers Squibb, Johnson & Johnson, and Pfizer. Drs Long and Dong have received honoraria for presentations from Johnson & Johnson and Abbott. The rest of the authors report no conflicts of interest.