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Challenges in AVNRT ablation in a patient with previous atrio-pulmonary Fontan
surgery: a case report
#MMPMID41384084
Jeewooth A
; Kaushik A
; Jaswal A
; Chakravarty A
Eur Heart J Case Rep
2025[Dec]; 9
(12
): ytaf569
PMID41384084
show ga
BACKGROUND: Patients with complex congenital heart defects, such as tricuspid
atresia, often require palliative surgical interventions like the Fontan
procedure to optimize systemic and pulmonary circulation. While these surgeries
improve survival rates, they are associated with long-term complications,
including arrhythmias, due to significant anatomical and electrophysiological
alterations. Among these, atrioventricular nodal reentrant tachycardia (AVNRT) is
relatively uncommon but poses substantial challenges in diagnosis and management.
CASE SUMMARY: This case report describes a 36-year-old male with a history of
tricuspid atresia and atrio-pulmonary Fontan surgery who presented with
symptomatic recurrent palpitations. Electrophysiological (EP) study revealed an
atypical variant of AVNRT, necessitating a complex ablation strategy. The unique
anatomical considerations in this patient, including a hypoplastic right
ventricle, a dilated and tortuous coronary sinus, and difficulty in defining the
Triangle of Koch, complicated the identification of the compact atrioventricular
(AV) node. Conventional catheter placement techniques were inadequate, and a
retrograde aortic approach was employed to localize His bundle potentials on the
left side of the septum. Advanced 3D electroanatomic mapping was used to
construct a virtual geometry of the right atrium, which guided the identification
and ablation of the slow pathway. Despite challenges in re-inducing the
tachycardia during the procedure, successful slow pathway modification was
achieved, and no recurrence of tachycardia was observed during follow-up.
DISCUSSION: Fontan anatomy poses unique procedural risks and requires a
multidisciplinary approach involving paediatric interventional cardiologists,
radiologists, and electrophysiologists. The findings of this case underscore the
critical importance of pre-procedural planning, detailed anatomical assessment,
and advanced imaging techniques to achieve favourable outcomes.
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