Accessory pathway ablation during atrial fibrillation in Ebstein anomaly

Area of Science:

• Cardiology
• Electrophysiology
• Medical Imaging

Background:

• Wolff-Parkinson-White (WPW) syndrome, characterized by accessory pathway (AP) conduction, can lead to rapid wide QRS tachycardia, particularly when associated with atrial fibrillation (AF).
• Ebstein anomaly, a congenital heart defect, presents unique challenges in managing arrhythmias like WPW and AF.
• Heart failure is a potential complication of sustained tachyarrhythmias in patients with underlying structural heart disease.

Observation:

• An 84-year-old female patient with type B WPW and Ebstein anomaly presented with heart failure due to rapid wide QRS tachycardia from AP conduction and AF.
• Pre-ablation transesophageal echocardiography identified a left atrial thrombus, necessitating careful consideration during the ablation procedure.
• The patient underwent catheter ablation using a 3D mapping system while in AF, with intra-cardiac echocardiography used to identify the functional tricuspid annulus.

Findings:

• A 3D intra-cardiac electrogram visualization (ripple map) during AF facilitated precise localization of the accessory pathway.
• Successful ablation of the accessory pathway was achieved without complications such as cerebral infarction.
• The patient's heart failure symptoms significantly improved post-ablation.

Implications:

• This case highlights the efficacy of 3D electroanatomical mapping and intra-cardiac echocardiography for complex accessory pathway ablation in patients with atrial fibrillation and structural heart disease.
• The successful management of this high-risk patient underscores the safety and effectiveness of contemporary ablation techniques in preventing thromboembolic events.
• Improved arrhythmia control led to a resolution of heart failure symptoms, demonstrating the significant impact of successful ablation on patient outcomes.