Atrial Fibrillation Ablation Without Pulmonary Vein Isolation in a Patient with Fontan Palliation.

In a patient with Fontan palliation and persistent atrial fibrillation two triggers were identified that initiated atrial fibrillation (AF) from the superior vena cava (SVC) and the right atrium. SVC triggers are more common in patients with a normal-sized left atrium. Eliminating these triggers prevented AF from being sustained in this patient and thus pulmonary vein isolation was not pursued. The patient has remained AF free for 3 years without medications or repeat ablation. Targeting of potential right-sided triggers for AF ablation, before pulmonary vein isolation, should be considered; such an approach may reduce risks in these complex patients.

A Case of Cough-induced Ventricular Tachycardia in a Patient with a Left Ventricular Assist Device.

In this case, the patient's ventricular tachycardia (VT) was specifically induced by coughing, which has not previously been described. Decreasing the rotational speed of the left ventricular assist device (LVAD) and increasing preload by stopping the patient's nitrates and reducing diuretic dose allowed improved filling of the left ventricle (LV) and increased LV volumes. When coughing recurred, the effects on the LV cavity were less pronounced and thus VT was reduced. Although ventricular arrhythmias are common after LVAD placement, this is a unique case in which VT was caused by coughing, which is ordinarily not considered arrhythmogenic.

Slow Pathway Modification in a Patient with D-Transposition of the Great Arteries and Atrial Switch Procedure.

Patients with systemic right ventricles are often not able to tolerate frequent, rapid, or incessant atrial arrhythmias without developing significant symptoms and ventricular dysfunction. Atrial arrhythmias are associated with an increased risk of ventricular arrhythmias and sudden cardiac death. Rhythm disturbances must be aggressively addressed in this population with frequent screening, follow-up, and treatment.

Ventricular Tachycardia in Congenital Pulmonary Stenosis.

With modern surgical techniques, there is significantly increased life expectancy for those with congenital heart disease. Although congenital pulmonary valve stenosis is not as complex as tetralogy of Fallot, there are many similarities between the 2 lesions, such that patients with either of these conditions are at risk for ventricular arrhythmias and sudden cardiac death. Those patients who have undergone surgical palliation for congenital pulmonary stenosis are at an increased risk for development of ventricular arrhythmias and may benefit from a more aggressive evaluation for symptoms of palpitations or syncope.

Preprocedural imaging in patients with transposition of the great arteries facilitates placement of cardiac resynchronization therapy leads.

OBJECTIVE: The purpose of this study is to review a series of patients with complex congenital heart disease in whom preprocedural imaging was used to assist placement of cardiac resynchronization therapy (CRT) leads. BACKGROUND: CRT may be beneficial in patients with a failing systemic ventricle and transposition of the great arteries (TGA). However, complex coronary venous anatomy can be challenging for placement of CRT leads. METHODS: Between October 2006 and June 2012, seven patients with either dextro-TGA (d-TGA) or levo-TGA (l-TGA) underwent preprocedural imaging prior to placement of CRT leads (three, d-TGA and four, l-TGA). Three patients underwent cardiac computed tomography (CT) and four underwent coronary angiography, which included levophase imaging of the coronary sinus (CS) or direct contrast injection of the CS. Where CS anatomy was appropriate with drainage into the systemic venous circulation, a transvenous approach was planned. In all other cases, the patient was referred for surgical placement of epicardial leads. RESULTS: Seven patients were identified with either d-TGA or l-TGA who had undergone preprocedural imaging prior to placement of CRT leads (three, d-TGA and four, l-TGA). Three patients underwent cardiac CT and four underwent coronary angiography, which included levophase imaging of the CS or direct contrast injection of the CS. All seven patients had successful CRT lead placement guided by preprocedure imaging. Three patients required surgical placement whereas four were able to undergo transvenous placement. There were no complications. The majority of patients (four of seven) had improvement in New York Heart Association class as well as subjective improvement in exercise tolerance and energy. The majority of patients also had subjective improvement in systemic right ventricular function by echocardiogram and objective improvement in fractional area change of the right ventricle. The follow-up period ranged from 13 months to 55 months with a mean follow-up of 39 months. CONCLUSIONS: Placement of biventricular leads for CRT in patients with l-TGA or d-TGA is feasible. Preprocedural imaging of the CS allows for better assessment of its anatomy and helps determine procedural approach for CRT placement, thereby limiting unnecessary procedures. In the majority of patients, there was subjective improvement in functional status and right ventricular function; in addition, there was objective improvement in echocardiographic parameters of right ventricular function after CRT placement.