Europace Advance Access originally published online on June 12, 2008
Europace 2008 10(8):1004-1005; doi:10.1093/europace/eun163
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
SHORT COMMUNICATIONS
Anatomically left-sided septal slow pathway ablation in dextrocardia and situs inversus totalis
1 Department of Cardiology, Athens Euroclinic, 9 Athanassiadou Street, Athens 11521, Greece; 2 Department of Pediatric Cardiology, Mitera Hospital, Athens, Greece
Manuscript submitted 26 April 2008. Accepted after revision 22 May 2008.
* Corresponding author. Tel: +30 210 6416600; fax: +30 210 6416661. E-mail address: dkatritsis{at}euroclinic.gr
 |
Abstract |
|---|
 Top Abstract References |
|---|
We present a case of typical (slow–fast) atrioventricular nodal re-entrant tachycardia in a patient with complete situs inversus in whom catheter ablation of the slow pathway was accomplished from the right-sided anatomically left ventricle with considerable ease.
Key Words: Atrioventricular nodal re-entrant tachycardia, Dextrocardia, Situs inversus, Ablation
Catheter ablation of atrioventricular nodal re-entrant tachycardia (AVNRT) in the setting of congenital heart disease is potentially very challenging, especially when associated with deviations from the usual situs solitus arrangement of atria and viscera. There have been reports of successful slow pathway ablation in patients with dextrocardia and situs inversus but usually at the expense of prolonged procedure and fluoroscopy times.1
–3
A 29-year-old lady with chronic renal failure and dextrocardia and complete situs inversus was referred for evaluation of paroxysmal narrow-complex tachycardia. Electrophysiological testing was undertaken and revealed dual AV nodal physiology and typical (slow–fast) AVNRT. A conventional ablation catheter, a D-curve with a 4 mm tip and 2.5 mm interelectrode spacing (Cordis-Webster, Diamond Bar, CA, USA), was introduced through the right femoral vein, and mapping of the slow pathway in the posterior area of the left-sided (anatomically right) septum was commenced. Despite recording of suitable electrograms (Figure 1), delivery of radiofrequency current (preset at 60°C and 45 W) failed to produce nodal activity and tachycardia remained inducible. Having completed 30 min of fluoroscopy time with attempts at posterior and mid-septal sites and inside the coronary sinus ostium, it was decided to approach the slow pathway from the arterial side. A second ablation catheter was introduced in the anatomically left ventricle through the right femoral artery, and the right side (anatomically left) of the septum was mapped for stable recording of a His bundle electrogram. From this position, the catheter tip was directed towards the ostium of the coronary sinus at the posterior aspect of the septum (Figure 2). This is the anatomic position of the left posterior extension of the AV node.4,5 Two deliveries of a radiofrequency current for 60 s resulted in immediate nodal rhythm with 1:1 retrograde conduction. After these applications, AVNRT was not inducible despite maximal doses of isoproterenol. The AH interval remained unchanged and there was no evidence of slow pathway conduction.
|
|
We have recently provided evidence in support of the notion that the right and left inferior nodal extensions of the human AV node and the atrio-nodal inputs they facilitate may provide the anatomic substrate of the slow pathway.4
,5 Our studies have indicated the presence of an atrio-nodal connection that is operating on the left side of the septum and corresponds to the leftward atrial inferior extension of the AV node. These observations provide the rationale for the well-documented feasibility of left-sided ablation of AVNRT. Dextrocardia in the context of complete situs inversus presents an anatomic challenge, and the left-sided approach may be of particular help by means of providing an accessible target for slow pathway ablation. Conflict of interest: none declared.
|
References |
|---|
|
TopAbstractReferences |
|---|
[1] Reithmann C, Hoffmann E, Dorwarth U, Remp T, Steinbeck G. Slow pathway ablation in a patient with common AV nodal reentrant tachycardia and complete situs inversus. Europace (1999) 1:283–5.
[2] Hirai Y, Chou CC, Wen MS. Catheter ablation of atrioventricular nodal reentrant tachycardia in a patient with complete situs inversus, atrial septal defect and ‘inverse’ persistent left superior vena cava. Int J Cardiol (2007) 115:e12–4.[CrossRef][Medline]
[3] Pecoraro R, Proclemer A, Pivetta A, Gianfagna P. Radiofrequency ablation of atrioventricular nodal tachycardia in a patient with dextrocardia, inferior vena cava interruption, and azygos continuation. J Cardiovasc Electrophysiol (2008) 19:444.[CrossRef][Web of Science][Medline]
[4] Katritsis DG, Becker AE, Ellenbogen KA, Karabinos I, Giazitzoglou E, Korovesis S, et al. The right and left inferior extensions of the atrioventricular node may represent the anatomic substrate of the slow pathway in the human. Heart Rhythm (2004) 1:582–6.[CrossRef][Web of Science][Medline]
[5] Katritsis DG, Becker A. The atrioventricular nodal reentrant tachycardia circuit: a proposal. Heart Rhythm (2007) 4:1354–60.[CrossRef][Web of Science][Medline]
CiteULike 
Connotea 
Del.icio.us What's this?
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||