Catheter Ablation of Atrioventricular Nodal Reentrant Tachycardia in Patients With Congenital Heart Disease

Abstract

Atrioventricular nodal reentrant tachycardia represents the most common regular supraventricular arrhythmia in humans, and catheter ablation of the so called slow atrioventricular nodal pathway has been effectively performed for decades. In patients with congenital heart disease, a combination of different factors makes catheter ablation of atrioventricular nodal reentrant tachycardia substrate particularly challenging, including abnormal venous access to intracardiac structures, abnormal intracardiac anatomy, potentially deviant and often unpredictable sites of the specific conduction system, loss of traditional anatomic landmarks, and congenital cardiac surgery that may complicate the access to the atrioventricular nodal area. Published experiences have confirmed the efficacy and the relative safety of such procedures when performed by experts, but the risk of complications, in particular atrioventricular block, remains non-negligible. A thorough knowledge and understanding of anatomic and electrical specificities according to underlying phenotype are essential in addressing these complex cases. Considering the major consequences associated with atrioventricular block in patients with complex congenital heart disease, particularly those without low risk access for transvenous ventricular pacing (eg, single ventricle physiology or Eisenmenger syndrome), the individual risk-benefit ratio should be carefully evaluated. The decision to defer ablation may be the wisest approach in selected patients with either infrequent or hemodynamically tolerated arrhythmias, or when the location of the atrioventricular conduction pathways remains uncertain. This narrative review aims to synthetize existing literature on catheter ablation of atrioventricular nodal reentrant tachycardia in congenital heart disease, to present main features of common associated pathologies, and to discuss approaches to mapping and safely ablating the slow atrioventricular nodal pathway in challenging cases.

Atrial fibrillation ablation in a single atrium with inferior vena cava interruption

“…Hasanin & Kinsara ( 2008 ) reported the case of a 24‐year‐old soldier with syncopal attacks attributed to paroxysmal complete AV block in the setting of SA with persistent LSVC. Catheter ablation may be difficult in patients with congenital heart disease, because of potentially deviant and often unpredictable sites of the specific conduction system (Waldmann et al, 2022 ). Khairy et al ( 2007 ) reported a case of inverted AV nodal input in a 25‐year‐old patient with surgically repaired partial AV canal defect.…”