Radiofrequency ablation of a fascicular tachycardia after orthotopic cardiac transplantation

Abstract

A 51 year old male received an orthotopic transplant because of end stage ischaemic heart disease. The donor was a healthy male teenager with no history of arrhythmias or other cardiac conditions. The patient presented with haemodynamically stable tachycardia and dyspnoea five weeks post-transplant. The ECG showed a regular tachycardia of 140 beats/min with a right bundle branch block morphology, left axis deviation, and a QRS duration of 135 ms. There were independent P waves, capture, and fusion beats confirming the diagnosis of ventricular tachycardia. Endomyocardial biopsy showed moderate focal rejection that was thought to be responsible for the arrhythmia. During the following six months the patient had recurrent tachyarrhythmias; on each occasion the ECG morphology was the same and there was no cellular rejection. The patient continued to have frequent hospital admissions with ventricular tachycardia requiring DC cardioversion despite the empirical use of amiodarone, sotalol, disopyramide, and procainamide. Eighteen months after transplantation the diagnosis of fascicular tachycardia was suspected by ECG morphology and supported by successful termination with intravenous verapamil. The arrhythmia was successfully managed by radiofrequency ablation. This patient shows that arrhythmias following transplantation are not always related to rejection, and that other potentially reversible causes should be considered, particularly when the ECG during arrhythmia conforms to a classic configuration. (Heart 1998;79:414-416) Keywords: radiofrequency ablation; tachyarrhythmias; transplantationThe development of tachyarrhythmias in cardiac transplant patients is often taken as a possible indication of the development of acute rejection, but this is not necessarily the case. We describe a case of fascicular tachycardia after orthotopic cardiac transplantation and its successful management by radiofrequency ablation. Case historyThe patient was a 51 year old man who had received an orthotopic transplant because of end stage ischaemic heart disease. The donor was a healthy male teenager with no history of arrhythmias or other cardiac conditions and a normal resting electrocardiogram (ECG). The total ischaemic time of the donor heart was 4 hours and 40 minutes. Postoperative recovery was uneventful and the patient received routine immunosuppression with cyclosporin and azathioprine.The baseline ECG during sinus rhythm had a right bundle branch block configuration and right axis deviation with a QRS duration of 135 ms ( fig 1A).The patient presented with haemodynamically stable tachycardia and dyspnoea five weeks post-transplant. The ECG showed a regular tachycardia of 140 beats/min with a right bundle branch block morphology, left axis deviation, and a QRS duration of 135 ms. There were independent P waves, capture, and fusion beats (fig 1B) confirming the diagnosis of ventricular tachycardia. His biochemical profile was normal and echocardiography confirmed good ventricular function with an ejection fraction o...

Catheter Ablation of Supraventricular Tachycardia in the Transplanted Heart:

“…During a mean follow‐up of 9.3 months, only two patients with a successful ablation procedure had an arrhythmia recurrence. Although outside the scope of the present report, there has been one reported catheter ablation of ventricular tachycardia after cardiac transplantation, an idiopathic fascicular left ventricular tachycardia that was successfully treated with RF ablation 7 …”