RF ablation of incessant atrioventricular tachycardia after Carpentier operation with Kalangos ring due to Ebstein anomaly

  • Dr Artur Baszko, Pediatric Electrophysiology Laboratory and Department of Cardiology, University of Medical Sciences, Poznan, Poland
  • Prof Waldemar Bobkowski, Department of Pediatric Cardiology, University of Medical Sciences, Poznan, Poland
  • Dr Malgorzata Pawelec-Wojtalik, Department of Pediatric Cardiology, University of Medical Sciences, Poznan, Poland
  • Dr Krzysztof Czyz, Department of Pediatric Cardiology, University of Medical Sciences, Poznan, Poland
  • Prof Mariusz Wojtalik, Department of Pediatric Cardiac Surgery, University of Medical Sciences, Poznan, Poland
  • Prof Aldona Siwinska, Department of Pediatric Cardiology, University of Medical Sciences, Poznan, Poland
  • Prof Stefan Grajek, Poland

    • We present a 15-year old girl with Ebstein anomaly, significant tricuspid valve (TV) regurgitation, ASD II and initially asymptomatic WPW syndrome. Biodegradable Kalangos Ring was used for TV plasty with very good hemodynamic effect. Several weeks after the operation she presented persistent atrio-ventricular tachycardia (AVRT) with RBBB morphology (130-160/min). Tachycardia did not respond to antyarrhythmic therapy.
    Before ablation echocardiography showing good function of the TV with thick folding of the myocardium over the ring at the posterolateral wall. EPS confirmed the presence of atrioventricular pathway (AP) with slow bi-directional conduction. Single stimulus induced AVRT with long RP’ interval. The mapping of the posterior-to-lateral wall of the TV showed the broad zone of low amplitude potentials. The 4 mm tip RF ablation electrode was used and after 2 applications the tachycardia was terminated, but antegrade conduction over the AP was preserved. Several additional applications were only transiently successful thus the decision was made to use irrigated catheter. Linear application was performed with repeated cessation of conduction over the pathway, however the slow tachycardia was inducible. After several minutes the pathway become silent. During 6 months follow-up she did not experience tachycardia despite no antyarrhythmic therapy.
    This case reveals that implantation of biodegradable Kalangos Ring may change the electrical properties of the preexisting AP leading to incessant AVRT. In this situation the ablation of the pathway can be difficult due to a myocardial folding covering the pathway. Integrating echocardiography, angiography with irrigated electrode can be successful in abolition of the pathway.