Typical atrial flutter ablation12/10/2023 ![]() A decapolar mapping catheter (DecaNav Biosense Webster, Inc, Irvine, CA) was placed through a fixed-curve (SR0) sheath after difficulty cannulating the coronary sinus (CS) without a sheath was observed, and was placed partially into a posterolateral ventricular CS branch to optimize stability. An intracardiac echo (ICE) probe was placed, and a baseline ICE exam was performed the TTVR valve was well visualized on ICE, and ICE contours of the TTVR valve and CTI were obtained on the electroanatomic mapping system ( Figure 1). Vascular access was obtained via the right femoral vein. The CARTO3 system (Biosense Webster, Inc, Irvine, CA) was used for electroanatomic mapping. The patient was brought to the electrophysiology laboratory and the procedure performed under deep sedation. Given continued symptomatic arrhythmias, the decision was made to perform repeat RF catheter ablation. Over the following days the atrial CL was seen to decrease to ∼350 ms, followed by disorganization to persistent AF. Given persistent slow atrial flutter, flecainide was discontinued. Medically, she had been managed with flecainide and low-dose beta-blockers. She had undergone several prior radiofrequency (RF) catheter ablations for AF and AFl, which involved pulmonary vein isolation, posterior wall isolation, CTI ablation, and an anterior mitral line (mitral annulus to the right superior pulmonary vein) for treatment of perimitral flutter. Ventricular response was controlled at baseline but tachycardia to the 150s with associated symptoms of palpitations was observed with light activity. ![]() Device interrogation revealed an increasing burden of atrial arrhythmias over a period of months both before and after TTVR, and at the time of presentation she was in persistent atrial flutter with cycle length (CL) ∼400 ms. This is a case of a 71-year-old woman with a history notable for paroxysmal AF and AFl, tachycardia-bradycardia and sick sinus syndrome status post a dual-chamber pacemaker, heart failure with preserved ejection fraction, and severe TR, who had undergone TTVR with an EVOQUE 48 mm valve 3 weeks prior to presentation to the hospital with tachycardia and fatigue. 12 To our knowledge there are no reports of catheter ablation in a patient with a TTVR. 11 There has also been description of catheter ablation after other transcatheter valve procedures, including transcatheter aortic valve replacement. Successful ablation of cavotricuspid isthmus (CTI)-dependent AFl has previously been described in patients with surgical tricuspid valve replacements. 10 As minimally invasive management of TR becomes safer and more effective, the number of patients with a TTVR who also require invasive management of atrial arrhythmias will likely increase. Primary or idiopathic TR may lead to right atrial (RA) dilation and precipitate AF 8 or AFl, 9 while secondary TR may result from RA dilation caused by atrial arrhythmias. 6, 7Ītrial fibrillation (AF) and flutter (AFl) commonly coexist with TR, and either disease can perpetuate the other. 5 While TTVR remains experimental, published short- and medium-term outcomes suggest potential for benefit from this procedure. 4 Recently, transcatheter tricuspid valve replacement (TTVR) using the EVOQUE system has shown promise as a safe and effective treatment for patients with severe TR. 2, 3 Surgical management of isolated TR has traditionally been avoided owing to relatively high surgical risk. 1 This may be particularly true in patients with coexisting atrial arrhythmias. Tricuspid regurgitation (TR) is a common form of valvular heart disease and has been associated with adverse outcomes including heart failure and an increased risk of mortality.
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