Transconduit puncture for catheter ablation of atrial tachycardia in a patient with extracardiac Fontan palliation

Dave, Amish S.; Aboulhosn, Jamil; Child, John S.; Shivkumar, Kalyanam

doi:10.1016/j.hrthm.2009.10.037

Cited by 49 publications

(27 citation statements)

References 15 publications

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“…At the same time, the access to the arrhythmia substrate within the atrium may be much more difficult with these two latter modifications of the Fontan procedure, particularly in case of ECC without fenestration, requiring puncture of the tunnel or conduit, or a retrograde approach through the aorta. This may render effective ablation procedure much more difficult or impossible [17,18]. An example of these difficulties is our patient No.…”

Section: Discussionmentioning

confidence: 96%

Atrial tachycardia ablation in patients with a functional single ventricle after the Fontan surgery

et al. 2016

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A b s t r a c tBackground: Atrial tachyarrhythmias are a leading source of morbidity and mortality after Fontan-type procedures and antiarrhythmic drug therapy is often ineffective in these patients. Aim:To evaluate short-and long-term outcomes of radiofrequency current ablation for atrial tachycardia (AT) in patients after the Fontan procedure, and to report clinical, electrophysiological and electroanatomical characteristics of these arrhythmias. Methods:We retrospectively analysed data obtained in 8 patients (5 males, 3 females) after the Fontan procedure who underwent ablation for AT between 2002 and 2013. In order to compare the clinical impact of arrhythmia before and after ablation, we used the modified arrhythmia score, ranging from 0 (no arrhythmia activity) to 12 (very severe arrhythmia). In all patients, electroanatomical mapping using the CARTO system was performed, allowing semiquantification of low-voltage (< 0.5 mV) areas and scars.Results: Seven patients had an atriopulmonary connection and 1 patient had an extracardiac conduit. The mean patient age was 9.4 ± 3.1 years at the time of the Fontan procedure and 26.2 ± 4.6 years at the time of the first ablation. A total of 18 ablations were performed with no complications, 1 to 4 (median 2.5) procedures per patient. In patients who had more than 1 ablation, the mean time from the first to the last procedure was 34.8 months (range 1-64 months). In individual patients, 1 to 4 (median 2.5) different ATs were observed, with the mean tachycardia cycle length of 334 ± 95 ms. In 6 patients, low-voltage area (< 0.5 mV) comprised 25-50% of the right atrium, and in two others it comprised 10-25% and < 10% of the right atrium, respectively. Seven procedures were fully successful (ablation of all ATs), 7 were partially successful (ablation of only some AT, including clinical arrhythmia, but not of all ATs) and 4 were unsuccessful (failed ablation of clinical AT). The mean procedural, fluoroscopy and ablation times were 176 ± 54.6, 13.7 ± 5.7 and 21.7 ± 11.9 min, respectively. Freedom from arrhythmia during the mean follow-up of 58.6 ± 46 months (range 11-127 months) since the last procedure was obtained in 4 patients. The median arrhythmia score after the last ablation was significantly reduced compared to baseline (4.5 vs. 8; p < 0.05).Conclusions: Catheter ablation of AT in patients after the Fontan procedure is safe but its acute and long-term efficacy is limited. Due to complex and extensive substrate, along with complex anatomy, recurrences are frequent and patients may require repeat ablation procedures. Suppression of arrhythmia is associated with an improved clinical status of the patients.

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Section: Discussionmentioning

confidence: 96%

Atrial tachycardia ablation in patients with a functional single ventricle after the Fontan surgery

et al. 2016

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“…75 Difficulties crossing the Gore-tex tube resulted in deformation of a radiofrequency-powered transseptal needle. Efforts to position the dilator across the baffle failed.…”

Section: Managing Arrhythmias With the Standard Extracardiac Fontanmentioning

confidence: 99%

“…It was cautiously concluded that further studies are required to determine the safety of this procedure. 75 Safety hinges, in large part, on the premise that, over time, the inflammatory process results in fibrotic adhesion of the conduit to the pulmonary venous atrium, so as to eliminate the space between these 2 structures. Although this may be true in some, it cannot be predicted with certainty.…”

Section: Managing Arrhythmias With the Standard Extracardiac Fontanmentioning

confidence: 99%

Is the Extracardiac Conduit the Preferred Fontan Approach for Patients With Univentricular Hearts?

Khairy

Poirier

2012

Circulation

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“…Successful ablation was performed in an 11-year-old child with a double-inlet left ventricle, who underwent extracardiac Fontan at age 3. Dave et al 24 also reported "Transconduit puncture for catheter ablation of atrial tachycardia in a patient with extracardiac Fontan palliation." Successful ablation was performed in a 34-year-old patient with tricuspid atresia, who underwent Fontan conversion from an atriopulmonary Fontan to extracardiac Fontan at age 30.…”

Section: Advantage 4: Atrial Access For Electrophysiology Study May Smentioning

confidence: 99%

Is the Extracardiac Conduit the Preferred Fontan Approach for Patients With Univentricular Hearts?

Kogon

2012

Circulation

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W ith improvements in technology, operative technique, and critical care medicine, more and more children with congenital heart disease are surviving into adulthood. As they age, these patients are providing physicians with new challenges, and we are realizing the long-term consequences of our previous interventions. This oftentimes has changed the mode of treatment for subsequent children. Response by Khairy and Poirier on p 2515Fontan palliation for single-ventricle patients was first described in 1971. 1 The original approach was in the form of a classic atriopulmonary Fontan connection, bypassing the nonfunctional right ventricle. After recognizing the long-term complication of an atriopulmonary connection (right atrial dilation, arrhythmias, and thrombus formation), modifications have been made. The atriopulmonary connection has been abandoned in favor of modified Fontan anatomy and physiology.The modified Fontan can be performed by the use of an extracardiac conduit approach or a lateral tunnel approach. The extracardiac Fontan uses an external conduit to anastomose the inferior vena cava into the pulmonary arteries, whereas a lateral tunnel Fontan uses a baffle within the right atrium (Figure 1). Because the systemic venous pathway is completely separated from the right atrium with the extracardiac Fontan, it is more challenging for the electrophysiologist to access the heart for ablation. My aim is to demonstrate why "the extracardiac conduit is the preferred Fontan approach for patients with univentricular hearts."The extracardiac Fontan has several advantages over the lateral tunnel Fontan. Advantage 1: Reduced Cardiopulmonary Bypass and Ischemic TimesMinimizing cardiopulmonary bypass and ischemia may optimize early postoperative outcomes. In multiple studies, both prolonged cardioplegic arrest and extended cardiopulmonary bypass times have been associated with an increased risk of early postoperative death or Fontan failure. [2][3][4] The technique of Fontan construction often dictates whether cardiopulmonary bypass or a period of ischemic arrest are required. With the lateral tunnel Fontan, the right atrium is opened for creation of the inferior vena cava baffle, necessitating the use of cardiopulmonary bypass. In addition, a period of cardioplegic arrest is required to stop the heart to prevent air embolic events until the atrium is closed. With the extracardiac Fontan, the right atrium is not opened. Vascular control is achieved at the right atrial-inferior vena cava junction. The inferior vena cava is transected and sewn to the extracardiac conduit, and the cardiac opening is oversewn. Vascular control of the pulmonary arteries is then achieved, and the conduit is sewn to the right pulmonary artery. Last, side-biting clamps are placed on the right atrium and conduit to create a fenestration if desired. With the use of this

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Transconduit puncture for catheter ablation of atrial tachycardia in a patient with extracardiac Fontan palliation

Abstract: Our patient is a 34 year old male with functionally single (left) ventricle, with tricuspid atresia but not pulmonary stenosis/atresia, and with atrial septal defect (ASD), ventricular septal defect

Cited by 49 publications

References 15 publications

Atrial tachycardia ablation in patients with a functional single ventricle after the Fontan surgery

Atrial tachycardia ablation in patients with a functional single ventricle after the Fontan surgery

Is the Extracardiac Conduit the Preferred Fontan Approach for Patients With Univentricular Hearts?

Is the Extracardiac Conduit the Preferred Fontan Approach for Patients With Univentricular Hearts?

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