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Missing pouches in high-density mapping of atrial tachyarrhythmia in congenital heart diseases
Sit-Yee Kwok1, Tak-Cheung Yung1, Ngai-Lun Ho1
1Department of Paediatric Cardiology Queen Mary Hospital Hong Kong.
Insights
High-density mapping effectively treats atrial arrhythmias in congenital heart disease (CHD) patients, achieving high acute success rates. Careful identification of anatomical pouches is crucial for optimal outcomes.
Area of Science:
- Cardiology
- Electrophysiology
- Congenital Heart Disease
Background:
- High-density electroanatomical mapping for congenital heart disease (CHD) arrhythmias is underreported in the Chinese population.
- This study addresses the gap by evaluating its utility in a tertiary center.
Purpose of the Study:
- To assess the effectiveness and outcomes of high-density electroanatomical mapping-guided transcatheter ablation for atrial tachyarrhythmia in Chinese patients with CHD.
- To identify specific arrhythmia mechanisms and anatomical challenges in this population.
Main Methods:
- Retrospective review of 8 CHD patients undergoing transcatheter ablation with high-density mapping (Orion catheter, Rhythmia system) from 2017-2019.
- Analysis of mapping data, arrhythmia mechanisms, acute success, and follow-up outcomes, including substrate ablation and identification of anatomical pouches.
Main Results:
- Predominant mechanism was cavo-annulus isthmus-dependent reentry; 75% achieved acute success.
- Recurrence occurred in 50%, with 3 patients managed on medication.
- Multiple intra-atrial reentrant tachycardias (IARTs) were common; critical anatomical pouches were identified in 3 patients, missed initially.
Conclusions:
- High-density mapping enables high acute success rates for atrial arrhythmia ablation in CHD patients.
- Substrate ablation is often necessary for multiple IARTs.
- Awareness of and vigilance for anatomical pouches are essential for successful ablation in CHD.
Background:
The use of high-density electroanatomical mapping in the Chinese population for congenital heart disease (CHD) is not well reported.
Methods:
Retrospective review of consecutive transcatheter ablation of atrial tachyarrhythmia using high-density mapping for CHD patients (at least moderate complexity) in the only tertiary congenital heart center in the territory from January 2017 to January 2019 was conducted. Orion mapping catheter in Rhythmia system (Boston Scientific) was used to create activation and voltage maps. Parameters including mechanism of arrhythmia, acute success, and follow-up data were recorded.
Results:
Eight patients were identified (median age 35.5 years) who underwent transcatheter ablation of atrial arrhythmia. More than one reentry circuits of IART were identified in five patients. It took a median of 32.4 minutes with 15,952 (IQR 13,395-18,530) mapping points per map. Cavo-annulus isthmus-dependent mechanism was the predominant reentry mechanism. Acute success with the elimination of all inducible tachycardia was achieved in six patients (75%), and partial success in two patients. There was recurrence of atrial arrhythmia in four patients (50%), in which three patients could be maintained in sinus rhythm with low-dose antiarrhythmic medication. Targeted substrate ablation was performed in six patients with multiple IART circuits. Critical anatomical pouches were identified in three patients, which were missed in the initial mapping using Orion basket mapping catheter.
Conclusions:
High acute success rate of atrial arrhythmia ablation can be achieved using high-density anatomical mapping in CHD. Substrate ablation was required with multiple IART circuits identified. Vigilance should be sought to identify anatomical pouches.
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