Fig 4 - available via license: CC BY-NC-ND
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Left panel shows tachycardia cycle length (TCL) with A-A cycle variation preceding V-V variation suggesting that atrium drives the tachycardia. Right panel shows the same phenomena during cooling down of tachycardia before reversion to sinus rhythm
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... EAS of this site was significantly earlier than the atrial septal ones. So far, four previous reports have highlighted the origin of septal AT from posterior pulmonary valve synus in patients with ccTGA [1][2][3][4]. In these small case series, an EAS from -40 to -80ms was localized into the pulmonary valve sinus. ...
A 46-year-old woman with congenitally corrected transposition of the great arteries (ccTGA) associated to dextrocardia, situs viscerus inversus and left superior vena cava persistence presented with an incessant supraventricular tachycardia. Electrophysiological study was not conclusive in differential diagnosis of atrial tachycardia versus atypical atrioventricular nodal reentrant tachycardia, also due to the unconventional anatomy of the coronary sinus. By a comprehensive mapping of cardiac chambers, a double side slow-pathway was localized in both atrial chambers and subsequently ablated by radiofrequency delivery without tachycardia changes. Aortic root and cusps were devoid of electrical activity. The muscular part of the sub-pulmonary ventricle at the level of interatrial septum showed an earliest activation signal of -90ms and ablation of this site was effective in abolish the tachycardia. This is the first case to report technical concerns of septal atrial tachycardia ablation in cc-TGA associated with multiple anatomical malformations. Moreover, some peculiarities have been reported for the first time including the presence of double side atrio-ventricular nodal slow-pathway and atypical localization of the tachycardia origin into the muscular part of the sub-pulmonary ventricle instead of posterior pulmonary cusp.
... Several studies have previously reported the electrocardiogram and electrophysiological features as well as successful ablation of focal ATs only in patients with {S, L, L}-type ccTGA. [1][2][3][4] The majority of ATs shared the common features of anteroseptal ATs, eg, comparatively narrow P wave, positive in leads I and aVL, negative/positive in leads V 1 -V 2 , and negative/positive or isoelectric in inferior leads. 1 The P wave during AT was relatively narrower in the present case. However, the inferior leads of the P wave during AT were positive, which was different from the reported cases with {S, L, L}-type ccTGA. ...
Key Clinical Message
A 46‐year‐old woman with congenitally corrected transposition of the great arteries (ccTGA) associated with dextrocardia, situs viscerus inversus, and left superior vena cava persistence presented with an incessant supraventricular tachycardia. Electrophysiological study was not conclusive in differential diagnosis of atrial tachycardia versus atypical atrioventricular (AV) nodal reentrant tachycardia, also due to the unconventional anatomy of the coronary sinus. By a comprehensive mapping of cardiac chambers, a double side slow‐pathway was localized in both atrial chambers and subsequently ablated by radiofrequency delivery without tachycardia changes. Aortic root and cusps were devoid of electrical activity. The muscular part of the sub‐pulmonary ventricle at the level of interatrial septum showed an earliest activation signal of −90 ms and ablation of this site was effective in abolish the tachycardia. This is the first case to report technical concerns of septal atrial tachycardia ablation in ccTGA associated with multiple anatomical malformations. Moreover, some peculiarities have been reported for the first time including the presence of double‐side AV nodal slow‐pathway and atypical localization of the tachycardia origin into the muscular part of the sub‐pulmonary ventricle instead of posterior pulmonary cusp.
Background
The unique malformation of congenitally corrected transposition of the great arteries (cc-TGA) makes the pulmonary outflow tract (POT) a possible origin of atrial tachycardia (AT).
Objective
The purpose of this study was to investigate the mapping characteristics of ATs successfully ablated at the POT in cc-TGA patients.
Methods
Cc-TGA patients with AT eliminated at the POT were analyzed. Activation mapping of the atria and the POT was performed under the guidance of a 3-D electroanatomic mapping system. The activation pattern of these chambers was investigated, with the local activation time (LAT, using coronary sinus ostium as reference) of the earliest activation site (EAS) compared.
Results
AT eliminated at the POT was documented in 5/6 cc-TGA patients. The EAS was at the right anteroseptal region with LAT of 33 (21-120)ms in the right atrium, and at the septal wall with comparable LAT (26ms, 47ms and 26ms, P=0.604) in the left atrium. The EAS of the POT was in the vicinity of the left-facing pulmonary sinus cusp in 3 cases and the non-facing pulmonary sinus cusp in 2 cases, with LAT of 106 (28-134)ms preceding both atria. Ablation at this site successfully eliminated the AT in all 5 cases.
Conclusions
AT arising adjacent to the POT is not an uncommon tachycardia in patients with the situs solitus type cc-TGA, and can be safely eliminated by ablation targeting the EAS in the POT.
