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Narrow QRS tachycardia in CCTGA

Raja Selvaraj
Cardiac Electrophysiologist
Professor of Cardiology
JIPMER

  • 51-year-old woman
  • Being evaluated for congenital heart disease
  • Sudden onset palpitations
  • History of similar episodes in past

ECG

tachy_ecg.jpg

Adenosine bolus

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Adenosine bolus

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ECG after termination

sinus_ecg.jpg

Echocardiogram

Arrhythmias in CCTGA

  • Atrial flutter and atrial fibrillation
  • Orthodromic AVRT
  • AVNRT
  • Internodal tachycardia

EP study - Sinus rhythm

sinus_post_HIS.jpg

Twin AV nodes in CCTGA

  • Malalignment of IAS and IVS
    • May result in membranous VSD
    • May result in in failure of connection of the node in mid-septal region with the ventricle
    • Anterior AV node usually present
  • More common in Situs solitus and when there is no pulmonary atresia or stenosis

Bauteau et al. Cardiac Conduction System in Congenitally Corrected Transposition of the Great Arteries and Its Clinical Relevance. Journal of the American Heart Association. 2017;6:e007759

Example of twin AV nodes (different patient)

twin_nodes.jpg

Tachycardia induction

tachy_induction.jpg

tachy_1.jpg

  • VA conduction with His after A - ? AP

tachy_2.jpg

  • VA conduction with His after A - bystander His activation, ? AP
  • VH block with VA conduction - further confirms bystander His

tachy_3.jpg

  • VA conduction with His after A - bystander His activation, ? AP
  • VH block with VA conduction - further confirms bystander His
  • Short VA during tachycardia - not AVRT
  • Narrow QRS similar to sinus - antegrade conduction through another AV node

tachy_4.jpg

  • VA conduction with His after A - bystander His activation, ? AP
  • VH block with VA conduction - further confirms bystander His
  • Short VA during tachycardia - not AVRT
  • Narrow QRS similar to sinus - antegrade conduction through another AV node
  • Internodal tachycardia ? - A before His, tachy continues with VH block
  • Therefore, AVNRT involving inputs to anterior node

Anterior His

tachy_ant_his.jpg

Anterior His during sinus rhythm

sinus_ant_his.jpg

Schematic illustration

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schematic_sinus.jpg

schematic_tachy.jpg

Ablation

  • No response at usual slow pathway region
  • No response to ablation within the coronary sinus
  • Attempted to ablate at slow AV nodal input to anterior node

Unusual Atrioventricular Reentry Tachycardia in Congenitally Corrected Transposition of Great Arteries A Novel Site for Catheter Ablation. Amit Noheria, Samuel J. Asirvatham and Christopher J. McLeod Circulation: Arrhythmia and Electrophysiology. 2016;9:e004120

Ablation

junctional_abl.jpg

Plan if redo required

  • Electroanatomic mapping ?
  • Map retrograde activation
  • Resetting to identify antegrade pathway