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Catheter ablation in transposition of the great arteries with Mustard or Senning baffles

Published:November 28, 2008DOI:https://doi.org/10.1016/j.hrthm.2008.11.022
      Complete transposition of the great arteries (D-TGA) accounts for 5% to 7% of congenital heart defects. Although the arterial switch procedure has now replaced atrial redirection as the surgical procedure of choice, most adults today with D-TGA have had Mustard or Senning baffles. These surgeries involve extensive atrial reconstruction and predispose to sinus node dysfunction and atrial tachyarrhythmias.
      • Gelatt M.
      • Hamilton R.M.
      • McCrindle B.W.
      • et al.
      Arrhythmia and mortality after the Mustard procedure: a 30-year single-center experience.
      • Khairy P.
      • Landzberg M.J.
      • Lambert J.
      • O'Donnell C.P.
      Long-term outcomes after the atrial switch for surgical correction of transposition: a meta-analysis comparing the Mustard and Senning procedures.
      By 20 years after surgery, the prevalence of atrial tachyarrhythmias is approximately 25%, continues to increase with time, and is similar among patients with Mustard or Senning baffles.
      • Gelatt M.
      • Hamilton R.M.
      • McCrindle B.W.
      • et al.
      Arrhythmia and mortality after the Mustard procedure: a 30-year single-center experience.
      • Khairy P.
      • Landzberg M.J.
      • Lambert J.
      • O'Donnell C.P.
      Long-term outcomes after the atrial switch for surgical correction of transposition: a meta-analysis comparing the Mustard and Senning procedures.
      In our experience, intra-atrial reentrant tachycardia (IART) is the most common arrhythmia substrate, followed by nonautomatic focal atrial tachycardia (NAFAT) and atrioventricular (AV) nodal reentrant tachycardia.
      • Greene A.E.
      • Skinner J.R.
      • Dubin A.M.
      • et al.
      The electrophysiology of atrioventricular nodal reentry tachycardia following the Mustard or Senning procedure and its radiofrequency ablation.
      • Van Hare G.F.
      • Lesh M.D.
      • Ross B.A.
      • et al.
      Mapping and radiofrequency ablation of intraatrial reentrant tachycardia after the Senning or Mustard procedure for transposition of the great arteries.
      Accessory-pathway-mediated tachyarrhythmias and atrial fibrillation occur less frequently.
      • Khairy P.
      • Fournier A.
      • Mercier L.A.
      • Dubuc M.
      Wolff-Parkinson-white syndrome in d-transposition of the great arteries and mustard baffle.
      Table 1 summarizes the arrhythmias encountered in D-TGA.
      Table 1Arrhythmias in transposition of the great arteries with Mustard or Senning baffles
      Type of arrhythmia Relative prevalence Comments
      Bradyarrhythmia
       Sinus node dysfunction ***** More so in Mustard than Senning baffles
       AV block ** Predominantly if associated VSD or tricuspid valve surgery
      Tachyarrhythmia
       IART **** Most common atrial tachyarrhythmia
        Rotating around tricuspid valve **** Circuit typically includes portion in pulmonary venous atrium
        Other ** Circuit involving superior baffle lines is next most common
       Focal atrial tachycardia *** May coexist with IART
        Nonautomatic *** Predominantly around suture lines
        Automatic ** Typically junctional in nature
       AV nodal reentrant tachycardia ** Slow pathway most often in pulmonary venous atrium
       Atrial fibrillation * Some forms of IART may resemble atrial fibrillation
       Accessory-pathway-mediated tachycardia * Rare, unlike congenitally corrected transposition
       Ventricular tachycardia/fibrillation ** May be primary or secondary to atrial tachyarrhythmias
      Asterisks represent a relative ordinal scale ranging from uncommon (*) to highly prevalent (*****).
      AV = atrioventricular; IART = intra-atrial reentrant tachycardia; VSD = ventricular septal defect.

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