Adolescent Persistent Atrial Fibrillation Concomitant with Pectus Excavatum

Abstract

A 19-year-old man with pectus excavatum developed symptomatic persistent atrial fibrillation (AF). He had no remarkable medical history or comorbidities and had not exercised intensely during childhood. Electrical cardioversion and pre-treatment with amiodarone for two months failed to maintain sinus rhythm. Computed tomography before ablation revealed compression of the right and left atria between the sternal bone and vertebral bodies. Voltage mapping revealed that the right and left atrial voltages were preserved within the normal limit. However, radiofrequency catheter ablation successfully eliminated recurrent persistent AF. No recurrence was observed during eight months of follow-up.

Challenges of atrial fibrillation and atrial flutter ablation in patients with pectus excavatum

“…RFCA for AF, especially PVI, is an effective and well‐established procedure for maintaining sinus rhythm. Although the efficacy of RFCA for AF in patients with PE has not been demonstrated in a large clinical trial, several individual case reports have reported the same 5 . This is the first three‐patient case series showing efficacy and the various challenges imposed by PE during the ablation procedure.…”

“…This case series explains the importance of understanding abnormal cardiac anatomy and strategizing before ablation procedures in patients with structural defects like PE. 5 The presence of PE can cause rotation and displacement of the heart, imposing challenges during RFCA of AF. The challenges include difficult access to the CS due to sharp angulation, ablation of the CTI due to anatomic distortion, and challenges of PVI due to reduced anteroposterior diameter, minimizing freedom of catheter movement.…”

“…There is a strong association between the presence of chest wall deformities such as PE and AF. The association between PE and AF has been attributed to mechanisms like (1) mechanical stimulation of the LA and activation of vagal reflexes during swallowing, (2) mitral valve prolapse resulting from heart compression, (3) sympathetic nerve activation resulting from a low cardiac output due to compression of the right side of the heart, and (4) pulmonary hypertension associated with the PE 5 …”

“…Mechanical compression of the atria by the sternal bone and vertebral bodies can induce right and left atrial conduction abnormalities, including AF. 5 Pulmonary vein isolation (PVI) has proven to be an effective strategy for radiofrequency catheter ablation (RFCA) of AF. 6 However, PE imposes certain challenges during ablation due to the anatomic distortion that it causes.…”

“…Pectus excavatum (PE) is the most common congenital chest abnormality, occurring one in 1000 births. Mechanical compression of the atria by the sternal bone and vertebral bodies can induce right and left atrial conduction abnormalities, including AF 5 . Pulmonary vein isolation (PVI) has proven to be an effective strategy for radiofrequency catheter ablation (RFCA) of AF 6 .…”