Skip to Main Content

++

PATIENT STORY

++

KG is a 38-year-old woman with the diagnosis of transposition of the great arteries (TGA). She underwent an atrial switch operation at age 2 (Figure 13-1). Her first episode of atrial flutter occurred at age 11 and was refractory to antiarrhythmic drug therapy with multiple cardioversions and ultimately required permanent pacemaker implant to support drug therapy. A prior electrophysiologic (EP) study and radiofrequency ablation (RFA) was unsuccessful. She recently had an episode of atrial flutter while taking sotalol 120 mg bid and metoprolol 12.5 mg daily. Her symptoms abruptly began with exertion and including dizziness and dyspnea associated with ventricular rates greater than 200 bpm (Figure 13-2). She underwent cardioversion and beta-blocker dose titration but unfortunately could not tolerate higher beta-blockade. She was subsequently referred for repeat EP study. Two separate arrhythmias were induced, an atrial tachycardia that had not been seen clinically (Figure 13-3) and atrial flutter (Figures 13-4 and 13-5). Mapping was initially performed on the systemic venous side and the atrial tachycardia location was identified and ablated. In order to map the atrial flutter a transbaffle puncture was performed to access the tricuspid valve and the pulmonary venous side (Figure 13-6). Entrainment mapping was used to identify the circuit (Figure 13-5). The atrial flutter was successfully ablated (Figure 13-7) by placing lesions from the inferior vena cava (IVC) to the baffle on the systemic venous side and then from the baffle to the tricuspid valve on the pulmonary venous side (Figure 13-8). She has since had no recurrence of her atrial flutter.

++
FIGURE 13-1

Magnetic resonance imaging (MRI) of transposition of the great arteries following atrial switch operation. There is no access to the tricuspid valve from the systemic venous side or the IVC.

Graphic Jump Location
++
FIGURE 13-2

A 12-lead ECG showing clinical atrial flutter.

Graphic Jump Location
++
FIGURE 13-3

Atrial tachycardia induced in the electrophysiology laboratory with a cycle length of 300 ms. From top to bottom surface leads I, III, and aVF; ablation distal and proximal, left atrial appendage distal and proximal, 10 pole coronary sinus catheter distal (1, 2) to proximal (9, 10). 10 pole halo catheter proximal (9, 10) to distal (1, 2) and the right ventricular proximal and distal electrograms.

Graphic Jump Location
++
FIGURE 13-4

Atrioventricular block during catheter manipulation which makes the flutter waves easier to identify.

Graphic Jump Location
++
FIGURE 13-5

Entrainment mapping used to define flutter circuit. The post pacing interval (PPI) is 370 ms with a tachycardia cycle length (TCL) of 360 ms. The PPI-TCL of 10 ms ...

Want remote access to your institution's subscription?

Sign in to your MyAccess profile while you are actively authenticated on this site via your institution (you will be able to verify this by looking at the top right corner of the screen - if you see your institution's name, you are authenticated). Once logged in to your MyAccess profile, you will be able to access your institution's subscription for 90 days from any location. You must be logged in while authenticated at least once every 90 days to maintain this remote access.

Ok

About MyAccess

If your institution subscribes to this resource, and you don't have a MyAccess profile, please contact your library's reference desk for information on how to gain access to this resource from off-campus.

Subscription Options

AccessCardiology Full Site: One-Year Subscription

Connect to the full suite of AccessCardiology content and resources including textbooks such as Hurst's the Heart and Cardiology Clinical Questions, a unique library of multimedia, including heart imaging, an integrated drug database, and more.

$595 USD
Buy Now

Pay Per View: Timed Access to all of AccessCardiology

24 Hour Subscription $34.95

Buy Now

48 Hour Subscription $54.95

Buy Now

Pop-up div Successfully Displayed

This div only appears when the trigger link is hovered over. Otherwise it is hidden from view.