Radiofrequency catheter ablation of supraventricular tachycardia substrates after mustard and senning operations for d-transposition of the great arteries
Ronald J. Kanter, MD, FACC*,
John Papagiannis, MD ,
Michael P. Carboni, MD*,
Ross M. Ungerleider, MD, FACC ,
William E. Sanders, MD, FACC|| and
J. Marcus Wharton, MD, FACC
* Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina, USA
Department of Surgery, Duke University School of Medicine, Durham, North Carolina, USA
Department of Internal Medicine, Duke University School of Medicine, Durham, North Carolina, USA
Department of Pediatric Cardiology, Onassis Cardiac Surgery Center, Athens, Greece
|| Department of Internal Medicine, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
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Figure 1 Diagrams of the pulmonary venous atrium following Mustard (a–c) and Senning (d) operations as viewed from a right anterior oblique projection. They illustrate the variations of surgical handling of the coronary sinus and medial isthmus between the inferior vena cava orifice and the tricuspid valve. (a) Inferior atrial baffle suture line is placed posterior to the coronary sinus ostium, keeping it and nearly all of the medial isthmus on the pulmonary venous side (Patients 2, 10). (b) Suture line is in approximately the same location as in (a), but the ostium is surgically redirected posteriorly into the systemic venous atrium (Patients 1, 3, 6, 8). (c) Suture line is placed anterior to the coronary sinus ostium, keeping it and a large portion of the medial isthmus on the systemic venous side (Patients 4, 5). (d) Right atrial freewall edge (arrows), which serves as a roof over the systemic venous tube, is sutured posterior to the coronary sinus ostium, similar in location to (a) (Patients 9, 11). AVN = compact AV node; CSO = coronary sinus ostium; TV = septal leaflet of tricuspid valve; cross-hatched area = medial isthmus; shaded area = region of "slow" inputs into AV node; stippled area = region of "fast" inputs into AV node.
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Figure 2 Diagrams of surgical anatomy with suture lines and of typical electrode catheter placement in Mustard and Senning patients. All important structures posterior to the level of the tricuspid valve are shown. The pulmonary venous atrium and the systemic venous baffle (cutaway) are illustrated in the Mustard diagram. The circle representing the coronary sinus ostium (CS os) is broken to emphasize its inconstant relationship with the adjacent portion of the baffle’s suture line. In the Senning diagram, only the systemic venous atrium and the anterior atrial septal remnant portion of the pulmonary venous atrium are shown. See text for details. LA = left atrial catheter; LAA = left atrial appendage; LV = left ventricular catheter; MV = direction of mitral valve location; RAA = right atrial appendage.
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Figure 3 Posteroanterior (PA) and lateral (Lat) radiographs and electrograms during mapping for and ablation of the typical variety of AV node reentry tachycardia in Patient 9. (Bottom Left) The ablation catheter (Abl) was first used to identify the region of the His bundle using the retrograde aortic approach. (Bottom Right) The successful ablation site (Abl) of the "slow" inputs to the AV node. Radiographs on the left are lower magnification than those on the right. Baff = systemic venous baffle multipole catheter. Bipole 4 is most superior and bipole 7 most inferior; HLA = high anatomic left atrial catheter; LV = left ventricular catheter; PSRA = posteroseptal right atrial catheter. The electrograms are from the most proximal bipole. See text for details.
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Figure 4 Locations of radiofrequency ablation attempts in Mustard and Senning patients. Illustrated are lesion locations for supraventricular tachycardias successfully and unsuccessfully ablated. In patients whose tachycardias were successfully ablated, unsuccessful locations are not illustrated. In the Mustard diagram, the solid gray area represents the systemic venous atrium, and the stippled area, the isthmus between the tricuspid valve and inferior vena cava. In the Senning diagram, the systemic venous atrium is opened, approximating the anatomy from Figure 2. The right atrial freewall flap comprising the roof over the systemic venous (intercaval) atrium is also removed, revealing the entire atrial septal remnant. The portion remaining on the pulmonary venous atrial (PVA) side includes the tricuspid valve/inferior vena cava isthmus. See text for details. MV = mitral valve; SVA = systemic venous atrium; TV = tricuspid valve.
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