The Journal of Heart and Lung Transplantation

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Presentation transcript:

The Journal of Heart and Lung Transplantation Catheter ablation of organized atrial arrhythmias in orthotopic heart transplantation Yamina Mouhoub, MD, Mikael Laredo, MD, Shaida Varnous, MD, Pascal Leprince, MD, PhD, Xavier Waintraub, MD, Estelle Gandjbakhch, MD, PhD, Jean-Louis Hébert, MD, PhD, Robert Frank, MD, Carole Maupain, MD, Alain Pavie, MD, Françoise Hidden- Lucet, MD, Guillaume Duthoit, MD The Journal of Heart and Lung Transplantation DOI: 10.1016/j.healun.2017.07.022 Copyright © 2017 International Society for the Heart and Lung Transplantation Terms and Conditions

Figure 1 Sites of clinical and induced arrhythmias with initial and re-do procedures. (A) Biatrial anastomosis. Initial procedures (white rectangles) included 21 CTI-dependent AFL (CTI), 1 clinical FAT (12-pointed star) and 5 induced FAT (4-pointed star, 4 from the right anterosuperior anastomosis, 1 parahisian in the vicinity of the His bundle), which were not ablated. Electrical repermeation between the graft and the native atrium was present in 6 patients but in no case related to the clinical tachycardia (bidirectional dashed arrow). Re-do procedures (red rectangles): 3 CTI-dependent AFL (CTI) and 1 clinical perimitral flutter (ILMI). Usual ablation lines were performed for CTI block (black line), between inferior vena cava and medial TA. Re-do ablation indicated by red lines: mitral isthmus block was performed between the left inferior pulmonary vein and mitral annulus (ILMI). (B) Bicaval anastomosis. Seven CTI-dependent AFLs (black line) and 1 clinical perimitral AFL that was ablated twice at an anteroseptal site of slow conduction (ASMI; white and red lines): 1 inducible perimitral AFL dependent on the ILMI in the same patient (4-pointed star) and 1 clinical FAT (red 12-pointed star, local reentry originating from the CS ostium during a third procedure in the same patient). In both anastomoses, a pronounced 45° left oblique anterior view was used. AFL, atrial flutter; ASMI, anteroseptal mitral isthmus; CS, coronary sinus; FAT, focal atrial tachycardia; IVC, inferior vena cava; ILMI, inferolateral mitral isthmus; LA, left atrium; MA, mitral isthmus; RA, right atrium; SVC, superior vena cava; TA, tricuspid annulus. The Journal of Heart and Lung Transplantation DOI: (10.1016/j.healun.2017.07.022) Copyright © 2017 International Society for the Heart and Lung Transplantation Terms and Conditions

Figure 2 Catheter mapping and ablation of a perimitral flutter in a biatrial transplant recipient. (A) Anteroposterior (left) and posteroanterior (right) views of the 3D activation map of a clockwise perimitral flutter dependent on a posterolateral mitral isthmus (EnSite Velocity, St. Jude Medical). Electrograms recorded within the mitral isthmus (white arrow) show fragmented delayed potentials suggesting slow diastolic conduction. The remnants of the recipient heart left atrium and pulmonary veins (gray area) represent an area of dense scarring (bipolar voltage <0.05 mV). (B) Radiofrequency applications on the endocardial and epicardial sides (brown spots and yellow dots, respectively) of the mitral isthmus terminated the arrhythmia (not shown). (C) After ablation of the mitral isthmus and return to sinus rhythm, pacing from the LAA shows mitral isthmus block with CS activated from proximal (SC 3.4) to distal (SC 1.2) and a long, 176-millisecond, LAA-to-CS interval. RA electrograms of 2 dissociated activities: 1 with sharp electrograms concomitant with the paced P-wave with 1:1 atrioventricular conduction (red arrows) corresponding to the donor heart’s normal sinus rhythm, and a rapid regular activity with no atrioatrial or atrioventricular conduction, corresponding to the recipient‘s remnant right atrial tachycardia (gray arrows). (D) During the same procedure, activation mapping of this native atrial tachycardia demonstrated a focal source from the anterolateral native RA and conducting to the posterior native RA, interatrial septum, left atrium and pulmonary veins. Local electrograms show early fragmented potentials suggesting local reentry (white spot with yellow arrow). CS, coronary sinus; EPS, electrophysiologic study; LAA, left atrial appendage; RA, right atrium. The Journal of Heart and Lung Transplantation DOI: (10.1016/j.healun.2017.07.022) Copyright © 2017 International Society for the Heart and Lung Transplantation Terms and Conditions