![]() On the other hand, ICE is a useful tool for intraprocedural visualization of CTI anatomy and location with regard to the artificial valve ring in EA patients. Multislice CT angiography is an imaging modality that provides accurate information about the exact anatomical relations prior to the procedure. Poor catheter stability in the part of the CTI located in the functional RV could be one of the plausible explanations for the arrhythmia recurrence after the first ablation session. However, in this particular case they posed a problem for the ablation by necessitating RF lesions across the artificial valve to terminate the arrhythmia and establish bidirectional CTI block. These relations between the valve ring and the CTI are due to the specific surgical approach aimed at preventing postoperative conduction disturbances. The case presented in this report demonstrates a successfully ablated CTId AFL in a patient late after TVR for EA in whom a part of the CTI was located in the functional RV as shown by CT angiography and ICE. After a 30 min waiting period CTI block was still persistent and no arrhythmias were inducible with programmed atrial stimulation. This resulted in termination of the arrhythmia and subsequent bidirectional CTI block. Since the ventricular location of a part of the circuit was strongly suspected based on CT images, CARTO and entrainment from the CS os, lesions were delivered across the artificial valve ring, in the functional RV to complete the ablation line (Fig. Ablation lesions at the atrial side of the CTI did not terminate flutter. Based on these findings the patient was found to have clockwise CTId AFL and radiofrequency (RF) ablation was undertaken using a cooled tip ablation catheter. Entrainment from the part of the CTI that was situated on the atrial side of the prosthesis ring demonstrated PPI-TCL of 20 msec (Fig. Pacing from the CSos produced a PPI-TCL of 0 msec demonstrating that it was also a part of the circuit despite its location in the functional RV. Entrainment mapping at the lateral and anterior TA showed postpacing intervals minus tachycardia CL (PPI-TCL) differences of 20 msec or less signifying that those sites were within the circuit. The activation map clearly showed clockwise activation around the TA occupying the whole CL of the AFL which was strongly suggestive of a peritricuspid reentrant circuit (Fig. An electroanatomic mapping system (CARTO, Biosense Webster, Diamond Bar, CA, USA) was used to map the RA. The patient presented in AFl and intracardiac recordings suggested clockwise activation around the tricuspid annulus (TA) with a cycle length (CL) of 260 msec. A part of the CTI was also found to be situated subvalvularly (Fig. The CS ostium (CSos) was found to be situated on the ventricular side of the prosthesis ring with a dilated CS draining into the right ventricle (RV) (Fig. Prior to the procedure a multislice contrast-enhanced computed-tomographic (CT) angiography was carried out to visualize the exact anatomical relations between the prosthesis ring and the other structures of the right atrium (RA). She was referred to our institution because of persistent symptomatic atrial flutter and was scheduled for ablation. During both operations, the prosthesis ring had been sutured to the septum posteriorly, well above the AV node, in order to avoid injury to it, thus leaving the coronary sinus (CS) draining into the right ventricle. In 2002 she was reoperated for a symptomatic tricuspid stenosis and the prosthesis was replaced by another bioprosthesis following a right lateral atriotomy. A 41 year old female had undergone a TVR with a biological artificial valve in 1983 without atrial plication because of EA with a severe tricuspid regurgitation.
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