https://doi.org/10.1007/s00392-024-02526-y
1Universitätsmedizin Göttingen Herzzentrum, Klinik für Kardiologie und Pneumologie Göttingen, Deutschland
Case presentation:
A 74-year old female patient presented to our arrhythmia clinic with complaints of frequent palpitations and exertional dyspnea. ECG recordings during symptomatic episodes, by her primary care physician and cardiologist, revealed atrial fibrillation (AF) and typical atrial flutter (tAF). Her medical history included a pulmonary vein isolation (PVI) performed in 2006 due to paroxysmal AF. Additionally, the patient had a history of symptomatic severe tricuspid regurgitation, managed with a transcatheter tricuspid annulus reconstruction using the Cardioband™ System (Edwards Lifesciences, USA) in 2019, which led to a significant reduction in tricuspid regurgitation and improvement in her symptoms. The physical examination was unremarkable. The ECG at presentation revealed atrial fibrillation. The echocardiographic study showed a normal left ventricular systolic ejection fraction (LVEF 55%) and moderate residual tricuspid regurgitation. Laboratory workup indicated an increased NT-proBNP level (1281 ng/L).
Management and follow-up:
Due to the anatomical proximity of the Cardioband™ and the cavotricuspid isthmus, along with the potential procedural risks of ablation, the patient’s cardiologist opted for conservative therapy with amiodarone and later flecainide, rather than pursuing an ablative strategy. However, the antiarrhythmic therapy proved ineffective and was poorly tolerated. After careful consideration of the benefits and potential risks, the patient was scheduled for an electrophysiologic study. The procedure was performed under deep sedation with propofol. Electroanatomic and local activation time (LAT) mapping using the CARTO 3 system (Biosense Webster, USA) in both atria revealed perimitral flutter. During ablation in the left atrium (circumferential pulmonary veins isolation and anterior lines), the perimitral flutter terminated and typical atrial flutter started. Guided by fluoroscopy (Image 1) and the 3D mapping system, the cavotricuspid isthmus (CTI) was ablated, and the arrhythmia terminated during ablation. No further atrial tachycardias were inducible. An echocardiogram conducted post-ablation showed a well-functioning Cardioband™ with no signs of stenosis (mean pressure gradient 2 mmHg) and unchanged moderate regurgitation (Image 2). The patient maintained a stable sinus rhythm with no further episodes of palpitations.
Take home messages:
• Radiofrequency ablation is an effective therapeutic approach for treating atrial arrythmias
• A thorough medical history of previously implanted devices is essential for planning electrophysiologic studies.
• Conducting cavotricuspid isthmus ablation in the presence of a Cardioband™ system is feasible and safe when performed under the guidance of fluoroscopy and 3D mapping systems.