Left atrial appendectomy after failed catheter ablation of a focal atrial tachycardia originating in the left atrial appendage

Combination of electrophysiological mapping, radiofrequency catheter ablation, and atrial appendectomy in a 5-year-old girl with tachycardia-induced cardiomyopathy: a case report

BACKGROUND

Atrial tachycardia (AT) originating from the left atrial appendage (LAA) is uncommon and the most difficult arrhythmia to eliminate. Therefore, we present the case of a 5-year-old girl with tachycardia-induced cardiomyopathy (TIC) caused by AT originating from the LAA and successfully treated with RFCA associated to left atrial appendectomy. With resolution of AT, we observed a progressive improvement of LV function. The effectiveness and safety of this combination therapy were evaluated over a one-month follow-up period.

CASE PRESENTATION

A 5 -year-old female was evaluated for three days of incessant cough and a syncopal episode. Surface echocardiography and 24-hour monitoring showed that the infant had persistent atrial tachycardia. Echocardiography revealed an enlarged tele diastolic diameter (46.1 mm) and malfunctioning (EF 28.53%) left ventricle. The location of the lesion at the apex of the LAA was further confirmed by electrophysiological study and RFCA. After RFCA, the infant's ECG monitor showed that sinus rhythm was maintained for up to 22 h. Subsequently, atrial tachycardia recurred and sinus rhythm disappeared. Finally, atrial appendectomy was performed and sinus rhythm returned to normal.

CONCLUSIONS

The heart function of the infant improved and sinus rhythm was maintained, further demonstrating the safety and effectiveness of combined treatment with RFCA and atrial appendectomy after electrophysiological localization of AT from LAA to TIC.

Intact survival from severe cardiogenic shock caused by the first attack of atrial tachycardia treated with extracorporeal membrane oxygenation and surgical left atrium appendage resection: a case report

Background

Atrial tachycardia (AT) is rare in children and can usually be reversed to sinus rhythm with pharmacotherapy and cardioversion. We report a rare case of severe left-sided heart failure due to refractory AT.

Case presentation

A 12-year-old boy had AT with a heart rate of 180 beats/minute, which was refractory to any medication and defibrillation despite the first attack. Due to rapid cardiorespiratory collapse shortly after arriving at our hospital, central extracorporeal membrane oxygenation (ECMO) with left arterial venting was started immediately. Although AT persisted after that, it stopped on the 3rd day after admission following surgical resection of the left atrial appendage thought to be the source of AT. He was weaned off ECMO on the 7th day and ventilator on the 14th day.

Conclusions

The appropriate timing of central ECMO and surgical ablation were effective in saving this child from a life-threatening situation caused by refractory AT.

Epicardial ablation of focal atrial tachycardia arising from left atrial appendage in children

Focal left atrial tachycardia (FLAT) although a common cause of supraventricular tachycardia(SVT) among children, the one's arising from left atrial appendage (LAA) present a unique challenge for successful ablation because of anatomical location. We present two children with FLAT arising from the epicardial LAA, successfully mapped and ablated through percutaneuous epicardial approach.

Thoracoscopic resection of the left atrial appendage after failed focal atrial tachycardia ablation

BACKGROUND

This case series describes 3 patients with the unusual location of focal atrial tachycardia in the left atrial appendage who failed catheter ablation but were successfully treated by left atrial appendage resection by a totally thoracoscopic surgical technique.

METHODS

In all 3 cases, left atrial appendage resection was carried out by video-assisted thoracoscopic surgery using only 3 5- to 10-mm incisions, eliminating the need for median sternotomy or thoracotomy. An endoscopic stapler was used to resect the left atrial appendage at its base, successfully eliminating the source of the patients' focal atrial tachycardia.

RESULTS

The mean operative time was 84 minutes. All 3 patients tolerated the procedure without any complications and were discharged on postoperative day 3. At an average follow-up of 4.5 years, all patients remained asymptomatic and with normal ambulatory rhythm monitoring off all antiarrhythmic medications.

CONCLUSIONS

Surgical resection of the left atrial appendage using a totally thoracoscopic approach is a safe and successful treatment option for patients who have failed endocardial catheter ablation. This novel approach utilizes smaller incisions and shorter operative times than the more invasive surgical techniques previously described in the literature.

Management of focal atrial tachycardias originating from the atrial appendage with the combination of radiofrequency catheter ablation and minimally invasive atrial appendectomy

BACKGROUND

Focal atrial tachycardias (ATs) originating from the left and the right atrial appendage (AA) were the most difficult to eliminate.

OBJECTIVE

To evaluate the safety and long-term efficacy of minimally invasive surgical atrial appendectomy in combination with radiofrequency catheter ablation (RFCA) in the management of focal atrial appendage tachycardias (AATs).

METHODS

We included 42 consecutive patients with 42 AATs confirmed by activation mapping and contrast venography. Thirty of them were successfully managed with RFCA (RFCA-successful group), while the remaining 12 (28.6%) finally resorted to video-assisted thoracoscopic atrial appendectomy owing to RFCA failure (resort-to-surgery group). We searched for predictors of RFCA failure, and the need for surgery by using a binomial logistic regression model.

RESULTS

In the RFCA-successful group, 6 (20.0%) patients experienced recurrence and re-do ablation and 11 (36.7%) AATs originated from distal AAs. In the resort-to-surgery group, the tachycardias involved exclusively distal AAs and required more RFCA attempts compared with those of the RFCA-successful group (1.58 ± 0.51 vs 1.20 ± 0.41; P = .0165). During atrial appendectomy, incessant ATs were terminated immediately after resection of the AA at the base. Long-term success was achieved in all 42 patients with a follow-up of 29.1 ± 17.5 months. No complications occurred. Fourteen patients with tachycardia-induced cardiomyopathy recovered fully. We identified origin at distal AATs and longer time to tachycardia termination by ablation as predictors of RFCA failure and the need for surgical intervention.

CONCLUSION

ATs originating from the distal portion of AA were more refractory to RFCA. The combination of catheter ablation and video-assisted thoracoscopic atrial appendectomy was an effective strategy to manage AATs.