The electrophysiology of atrioventricular nodal reentry tachycardia following the Mustard or Senning procedure and its radiofrequency ablation

Greene, Anne E.; Skinner, Jonathan R.; Dubin, Anne M.; Collins, Kathryn K.; Hare, George F. Van

doi:10.1017/s1047951105001782

Cited by 20 publications

(24 citation statements)

References 25 publications

(33 reference statements)

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“…5,6,10 As did earlier investigators, 3,4 we found that IART, AVNRT, and NAFAT can all occur with clinical significance in this group of patients. Of note in our series, short-term success did not necessarily predict complete midterm success.…”

Section: Discussionsupporting

confidence: 81%

“…1 Investigators have since shown that atrioventricular (AV) nodal reentrant tachycardia (AVNRT) and nonautomatic focal atrial tachycardia (NAFAT) are also prevalent. 3,4 (Nonautomatic FAT is defined as an arrhythmia inducible with pacing maneuvers and presumably caused by microreentry or by triggered mechanisms.) Original attempts at radiofrequency ablation (RFA) in these patients were reasonably successful.…”

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confidence: 99%

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Effectiveness of Early Invasive Therapy for Atrial Tachycardia in Adult Atrial-Baffle Survivors

Bradley¹,

Zaidi

Morrison

et al. 2017

Texas Heart Institute Journal

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I nteratrial baffle procedures, such as Mustard or Senning operations, were the standard of care in the mid-to late 20th century for patients born with dextrotransposition of the great arteries (D-TGA). The surgical process of redirecting systemic and pulmonary venous circulation with complex baffling in the atria is a known risk factor for late atrial tachyarrhythmias.1 Newer surgical techniques, such as the atrial switch, have supplanted interatrial baffle operations.The substrate for late atrial tachyarrhythmia has historically been reported as atrial flutter or intra-atrial reentrant tachycardia (IART).1 Investigators have since shown that atrioventricular (AV) nodal reentrant tachycardia (AVNRT) and nonautomatic focal atrial tachycardia (NAFAT) are also prevalent.3,4 (Nonautomatic FAT is defined as an arrhythmia inducible with pacing maneuvers and presumably caused by microreentry or by triggered mechanisms.) Original attempts at radiofrequency ablation (RFA) in these patients were reasonably successful. 5 The increasing frequency of RFA has engendered newer transbaffle access (TBA) techniques that enable access to the pulmonary venous atrium (PVA). 6,7 The goal is to offer more lasting control of atrial arrhythmias.Our institution has experienced a notable increase in adult Mustard and Senning survivors who present with clinically significant, recurrent atrial arrhythmias. Antiarrhythmic agents are relatively ineffective and can have undesirable side effects. Using a strategy of early RFA intervention (after ≤1 trial of antiarrhythmic therapy) with atrial mapping, our team of adult and pediatric electrophysiologists studied short-and midterm RFA outcomes in adults with a prior Mustard or Senning procedure who presented at our institution over a period of one year for clinically significant arrhythmias.

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Section: Discussionsupporting

confidence: 81%

mentioning

confidence: 99%

Effectiveness of Early Invasive Therapy for Atrial Tachycardia in Adult Atrial-Baffle Survivors

Bradley¹,

Zaidi

Morrison

et al. 2017

Texas Heart Institute Journal

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“…In the other 3 patients with AVNRT in whom ablation was attempted, the application of RF energy to the low medial regions of the systemic venous atrium was unsuccessful, and a subsequent retrograde approach from the pulmonary venous side was required to eliminate the tachycardia. 6 Concordant with our findings, 2 of these 3 patients had bidirectional single-pathway physiology.…”

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confidence: 90%

Nonfluoroscopic Imaging as Guidance for Radiofrequency Ablation of Atrioventricular Nodal Reentrant Tachycardia after Mustard Repair

Hluchý¹,

Nguyen²,

Sobczak³

et al. 2017

Texas Heart Institute Journal

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M ustard repair for complete dextrotransposition of the great arteries (D-TGA) is associated with a 10% incidence of late recurrent atrial tachycardias.1 Most of these tachycardias (localized, as they are, in the pulmonary venous atrium) are not directly accessible for ablation and require either a retrograde approach or a transseptal approach. [2][3][4] We present a case of successful radiofrequency (RF) ablation of common atrioventricular nodal reentrant tachycardia (AVNRT), guided by nonfluoroscopic mapping with use of the EnSite NavX cardiac mapping system (St. Jude Medical, Inc.; St. Paul, Minn) in a patient who long before had undergone Mustard repair for D-TGA. Case ReportIn 2013, a 49-year-old woman with a 3-year history of recurrent supraventricular tachycardia at 175 beats/min (responsive to intravenous adenosine) was referred for catheter ablation. At the age of 4 years, she had undergone a Mustard repair for D-TGA. No detailed report of her surgical anatomy was available. Therefore, cardiac magnetic resonance imaging was performed before ablation: it showed the right and left pulmonary veins diverted to the right (pulmonary venous) atrium and the superior and inferior venae cavae (SVC and IVC) diverted by an atrial baffle to the left (systemic venous) atrium. A 12-lead electrocardiogram showed both sinus rhythm with criteria for right ventricular (RV) hypertrophy with right-axis deviation (Fig. 1A) and supraventricular tachycardia that suggested common AVNRT (Fig. 1B). During an electrophysiologic study performed after informed consent was obtained, diagnostic and ablation catheters were placed with use of fluoroscopy and were displayed on the screen of the EnSite NavX system. Via the right femoral vein, we deployed a 6F hexapolar catheter in the SVC for stimulation and recording from the pulmonary venous atrium, a 6F quadripolar catheter for stimulation and recording Case Reports

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“…[2 3] However, AVNRT should also be high on the list of possible diagnoses, as in the published short series of patients after Senning or Mustard operations who have undergone electrophysiological study for supraventricular tachycardia AVNRT was identified in 3 of 11 patients (27%) in the series of Kanter et al, [4] 4 of 34 (12%) in the study of Wu et al, [5] while Greene et al reported AVNRT in 4 of 18 patients (22%), [6] -with the remaining patients from these series diagnosed with intraatrial reentry. Despite being supraventricular, these arrhythmias may cause acute cardiac failure or sudden cardiac death due to the fast ventricular response.…”

Section: Commentarymentioning

confidence: 99%

Paroxysmal tachycardia in a patient after the Senning procedure for transposition of the great arteries

Jastrzębski¹,

Czarnecka²

2017

Heart Beat

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Key words:We describe a 19-year-old man with transposition of the great arteries, which had been corrected 14 years earlier with the Senning procedure, who experienced recurrent atrioventricular nodal reentrant tachycardia (AVNRT). The ablation procedure is described with a discussion and literature review concerning the possible and preferred slow pathway ablation strategy in such patients. atrioventricular nodal reentrant tachycardia; AVNRT; Senning procedure; ablation Case presentationWe describe a 19-year-old man with transposition of the great arteries, which had been corrected 14 years earlier (Senning procedure), who experienced recurrent tachycardia with incomplete right bundle branch block QRS morphology. Since the QRS morphology was identical to that during sinus rhythm and typical of patients with transposition of the great arteries (prominent features of right ventricular hypertrophy), he was presumptively diagnosed with supraventricular tachycardia (Figure 1). Complex cardiosurgical operations involving atrial tissue predispose to the occurrence of intraatrial reentry due to iatrogenic scars. [1] In the current case, however, the electrophysiological study resulted in a diagnosis of atrioventricular reentrant tachycardia (AVNRT) - Figure 2, panel A. The tachycardia had a cycle length of 380-520 ms, and a ventriculo-atrial interval of 60 ms was observed. Moreover, there was a V-A-V response to ventricular overdrive pacing, and the post-pacing interval was 158 ms longer than the tachycardia cycle length. With the support of a 3D system (EnSite NavX St. Jude Medical, Inc., St. Paul, MN, USA) we first tried to ablate the AVNRT substrate in the venous atrium near the His bundle potential with access via the inferior vena cava (Figure 2, panel B and Figure 3, panel A), but this attempt was unsuccessful and hazardous (non-conducted nodal ectopic beats during ablation with transient AH interval prolongation). It seemed that the venous atrium allowed access only to the upper part of the triangle of Koch with the His bundle and the fast atrioventricular node pathway. Therefore, a retrograde aortic approach to the systemic ventricle and then via the tricuspid valve to the area of typical localization of the slow pathway in the remnant of the anatomic right atrium ( Figure 2, panel C and Figure 3, panel B, black arrow) was used. An ablation catheter was positioned on the His bundle potential and pushed deeper into the atrium in a direction inferior and lateral to the His bundle potential to search for a small fragmented atrial potential. Application of radiofrequency current energy in this position (Figure 2, panel C, red dots) resulted in an accelerated nodal rhythm and arrhythmia non-inducibility, with no recurrences during 2 years of follow-up. Figure 2, panel D illustrates the anatomical route that can be used to

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The electrophysiology of atrioventricular nodal reentry tachycardia following the Mustard or Senning procedure and its radiofrequency ablation

Cited by 20 publications

References 25 publications

Effectiveness of Early Invasive Therapy for Atrial Tachycardia in Adult Atrial-Baffle Survivors

Effectiveness of Early Invasive Therapy for Atrial Tachycardia in Adult Atrial-Baffle Survivors

Nonfluoroscopic Imaging as Guidance for Radiofrequency Ablation of Atrioventricular Nodal Reentrant Tachycardia after Mustard Repair

Paroxysmal tachycardia in a patient after the Senning procedure for transposition of the great arteries

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