Supraventricular Tachycardia After Orthotopic Cardiac Transplantation
Marmar Vaseghi, MD*,
Noel G. Boyle, MD, PhD*,
Rohit Kedia, MD*,
Jignesh K. Patel, MD, PhD ,
David A. Cesario, MD, PhD*,
Isaac Wiener, MD*,
Jon A. Kobashigawa, MD and
Kalyanam Shivkumar, MD, PhD*,*
* UCLA Cardiac Arrhythmia Center, Division of Cardiology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
UCLA Heart Transplant Program, Division of Cardiology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California.
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Figure 1 Incidence of Atrial Flutter Versus Atrial Fibrillation
In the cohort of cardiac transplant patients, the percentage of patients with any atrial flutter and fibrillation as well as the individual arrhythmias associated with the appropriate clinical setting are shown. Stable was defined as those without simultaneous severe transplant vasculopathy, sepsis, or acute rejection who are not in the immediate post-operative period while experiencing the arrhythmia as shown. Note that no atrial fibrillation was observed in stable cardiac transplant patients. In comparison, atrial flutter occurred in 4.6% of patients and, in 2.3%, required electrophysiological study and ablation. AFib = atrial fibrillation; Aflutter = atrial flutter.
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Figure 2 Classification of SVT in Stable OHT Patients
Incidence of the different types of drug refractory supraventricular tachycardia (SVT) in this cohort of orthotopic heart transplant (OHT) patients who underwent electrophysiological study (EPS) is shown. Note that isthmus-dependent atrial flutter was the most commonly observed SVT, followed by scar-related macro-reentrant tachycardia. AT = atrial tachycardia; AVNRT = atrioventricular nodal reentrant tachycardia; AVRT = atrioventricular reentrant tachycardia.
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Figure 3 Left Atrial Macro-Reentrant Tachycardia
(A) Surface electrocardiogram demonstrates atrial tachycardia at a rate of 150 beats/min. (B) Activation maps demonstrate the tachycardia using an isthmus in the left atrium (LA), just anterior to the left superior pulmonary vein (LSPV), involving the donor, but not native (gray) left atrium (LA cuff tachycardia). Red marks represent ablation lesions. (C) Fluoroscopic left anterior oblique view: this tachycardia was mapped and ablated with transseptal catheterization. ABL = ablation catheter; CS = coronary sinus; LAT = left atrial tachycardia; LIPV = left inferior pulmonary vein; RA = right atrium; SCR = native atrium tagged as "scar" and shown in gray.
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Figure 4 Atrio-Atrial Anastomosis With Donor Isthmus Right Atrial Flutter and Dissociated Native Atrial Rhythm
(A) Fluoroscopic right anterior oblique view shows the position of the duodecapolar catheter with the distal bipoles (D1 to D3) along the tricuspid valve isthmus and the proximal electrode (D10) along the superior aspect of the interatrial septum. (B) Electroanatomic maps of atrio-atrial anastomosis (gray areas identify native atrial tissue). The flutter wave-front involves the donor atrium only and is propagating in a counterclockwise fashion along the tricuspid annulus. (C) Intracardiac activation sequence in the donor atrium confirms counterclockwise activation. A critical isthmus was located near D5 in the lateral right atrium wall. The native atrium was in a dissociated atrial rhythm (D6 to D9) and did not conduct to the donor atrium. Therefore, ablation of the native atrium was not performed. CS = coronary sinus; D1 to D10 = duodecapolar bipoles 1 to 10; DDC = duodecapolar catheter; LV = left ventricle; RV = right ventricle.
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Figure 5 LA (LIPV-Mitral Isthmus) Flutter
(A) Activation map: the flutter circuit begins in the inferior wall of the LA (pink) close to the CS3-4 bipole and propagates across to the RA and around the tricuspid annulus as well as around and over the mitral annulus. The ablation line, shown, successfully terminated the arrhythmia without recurrence during follow-up. (B) Fluoroscopic left anterior oblique view: an ablation catheter was placed in the LA and duodecapolar catheter in the RA for mapping. (C) Intracardiac tracings corresponding to the activation map in panel A showing the earliest activation in the LA and extending to the RA. LAA = left atrial appendage; RSPV = right superior pulmonary vein; SVC = superior vena cava; other abbreviations as in Figure 3.
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