Successful Ablation of Cavotricuspid Isthmus-dependent Atrial Flutter Guided by Contact Force Vector in a Patient After a Tricuspid Valve Replacement

Case Report: Remote magnetic navigation and accessory pathways ablation in a single ventricle young adult with complex corrective surgeries

Supraventricular arrhythmias have become an increasingly significant contributor to the risk of mortality and morbidity in adults with complex congenital heart disease (CHD), especially in light of recent advances in palliative corrective surgeries. Because of their unique characteristics, they demand specific treatment approaches. While pharmaco-logical interventions are an option, they have limited effectiveness and may lead to side effects. Although performing radiofrequency ablation (RFA) can be exceptionally challenging in patients with complex CHD, due to particular vascular access and also modified anatomy, it has paved the way to enhance comprehension of the underlying mechanisms of supraventricular arrhythmias. This, in turn, enables the provision of improved therapies and, ultimately, an enhancement in the quality of life and symptom management for these patients. The purpose of this case report is to highlight the benefits of utilizing advanced technologies such as three-dimensional electro-anatomical mapping systems, remote magnetic navigation, and highly flexible mapping and ablation catheters during RFA in a young adult with complex congenital heart disease. Although he lacked venous connections to the right atrium (RA) due to multiple corrective surgeries we, remarkably, were capable to advance a decapolar deflectable diagnostic catheter inside the Fontan tunnel and from there to record and stimulate the RA. Successful ablation of two accessory pathways was achieved with no arrhythmia recurrence during follow-up.

New developments in catheter ablation for patients with congenital heart disease

Introduction: There are numerous challenges to catheter ablation in patients with congenital heart disease (CHD), including access to cardiac chambers, distorted anatomies, displaced conduction systems, multiple and/or complex arrhythmia substrates, and excessively thickened walls, or interposed material. Areas covered: Herein, we review recent developments in catheter ablation strategies for patients with CHD that are helpful in addressing these challenges. Expert opinion: Remote magnetic navigation overcomes many challenges associated with vascular obstructions, chamber access, and catheter contact. Patients with CHD may benefit from a range of ablation catheter technologies, including irrigated-tip and contact-force radiofrequency ablation and focal and balloon cryoablation. High-density mapping, along with advances in multipolar catheters and interpolation algorithms, is contributing to new mechanistic insights into complex arrhythmias. Ripple mapping allows the activation wave front to be tracked visually without prior assignment of local activation times or window of interest, and without interpolations of unmapped regions. There is growing interest in measuring conduction velocities to identify arrhythmogenic substrates. Noninvasive mapping with a multielectrode-embedded vest allows prolonged bedside monitoring, which is of particular interest in those with non-sustained or multiple arrhythmias. Further studies are required to assess the role of radiofrequency needle catheters and stereotactic radiotherapy in patients with CHD.