Ablation for unmappable ventricular tachycardia in a patient with complete transposition of the great arteries who underwent Rastelli repair

Published:October 22, 2021DOI:https://doi.org/10.1016/j.jccase.2021.09.012


      Catheter ablation (CA) of ventricular tachycardia (VT) after repair of congenital heart disease may be difficult because of complex anatomy and sometimes unmappable VT. Here, we report a 41-year-old woman with successful CA of unmappable VT in a patient with complete transposition of the great arteries after Rastelli repair. Clinical VT was induced by programmed electrical stimulation, when the mapping catheter was placed at the high anterior right ventricular outflow tract (RVOT). During VT, the local potential at the high anterior RVOT under the right ventricle (RV) – pulmonary artery (PA) conduit was equal to that at the timing of onset of QRS. The VT was unmappable because the hemodynamics deteriorated. Pace mapping was also tried at the aortic cusp and the left ventricular outflow tract (LVOT). Fractionated potential during sinus rhythm was observed at the noncoronary cusp, and the paced QRS morphology at this site was similar to that of the clinical VT, with a delay of 55 ms from pacing to the onset of QRS. However, mapping at the LVOT was impossible due to the difficulty of catheter manipulation. Radiofrequency energy was successfully applied at the noncoronary cusp and the high anterior RVOT under the RV-PA conduit.

      Key words

      To read this article in full you will need to make a payment


        • Khairy P.
        • Van Hare G.F.
        • Balaji S.
        • Berul C.I.
        • Cecchin F.
        • Cohen M.I.
        • Daniels C.J.
        • Deal B.J.
        • Dearani J.A.
        • Groot N.d.
        • Dubin A.M.
        • Harris L.
        • Janousek J.
        • Kanter R.J.
        • Karpawich P.P.
        PACES/HRS Expert Consensus Statement on the Recognition and Management of Arrhythmias in Adult Congenital Heart Disease: developed in partnership between the Pediatric and Congenital Electrophysiology Society (PACES) and the Heart Rhythm Society (HRS). Endorsed by the governing bodies of PACES, HRS, the American College of Cardiology (ACC).
        the American Heart Association (AHA), the European Heart Rhythm Association (EHRA), the Canadian Heart Rhythm Society (CHRS), and the International Society for Adult Congenital Heart Disease (ISACHD). Heart Rhythm. 2014; 11: e102-e165
        • Hernandez-Madrid A.
        • Paul T.
        • Abrams D.
        • Aziz P.F.
        • Blom N.A.
        • Chen J.
        • Chessa M.
        • Combes N.
        • Dagres N.
        • Diller G.
        • Ernst S.
        • Giamberti A.
        • Hebe J.
        • Janousek J.
        • Kriebel T.
        Arrhythmias in congenital heart disease: a position paper of the European Heart Rhythm Association (EHRA), Association for European Paediatric and Congenital Cardiology (AEPC), and the European Society of Cardiology (ESC) Working Group on Grown-up Congenital heart disease, endorsed by HRS, PACES, APHRS, and SOLAECE.
        Europace. 2018; 20: 1719-1753
        • Zeppenfeld K.
        • Schalij M.J.
        • Bartelings M.M.
        • Tedrow U.B.
        • Koplan B.A.
        • Soejima K.
        • et al.
        Catheter ablation of ventricular tachycardia after repair of congenital heart disease: electroanatomic identification of the critical right ventricular isthmus.
        Circulation. 2007; 116: 2241-2252
        • Kriebel T.
        • Saul J.P.
        • Schneider H.
        • Sigler M.
        • Paul T.
        Noncontact mapping and radiofrequency catheter ablation of fast and hemodynamically unstable ventricular tachycardia after surgical repair of tetralogy of Fallot.
        J Am Coll Cardiol. 2007; 50: 2162-2168
        • Sherwin E.D.
        • Triedman J.K.
        • Walsh E.P.
        Update on interventional electrophysiology in congenital heart disease: evolving solutions for complex hearts.
        Circ Arrhythm Electrophysiol. 2013; 6: 1032-1040
        • Koa-Wing M.
        • Linton N.W.
        • Kojodjojo P.
        • O'Neill M.D.
        • Peters N.S.
        • Wyn Davies D.
        • Kanagaratnam P.
        Robotic catheter ablation of ventricular tachycardia in a patient with congenital heart disease and Rastelli repair.
        J Cardiovasc Electrophysiol. 2009; 20: 1163-1166
        • Wilson N.J.
        • Clarkson P.M.
        • Barratt-Boyes B.G.
        • Calder A.L.
        • Whitlock R.M.
        • Easthope R.N.
        • Neutze J.M.
        Long-term outcome after the mustard repair for simple transposition of the great arteries. 28-year follow-up.
        J Am Coll Cardiol. 1998; 32: 758-765
        • Kammeraad J.A.
        • van Deurzen C.H.
        • Sreeram N.
        • Bink-Boelkens M.T.
        • Ottenkamp J.
        • Helbing W.A.
        • Lam J.
        • Sobotka-Plojhar M.A.
        • Daniels O.
        • Balaji S.
        Predictors of sudden cardiac death after Mustard or Senning repair for transposition of the great arteries.
        J Am Coll Cardiol. 2004; 44: 1095-1102