Right ventricular outflow tract ventricular tachycardia ablation post-Rastelli repair

Abstract

We present a case of right ventricular outflow tract (RVOT) ventricular tachycardia (VT) ablation following remote Rastelli repair. The patient was born with a double-outlet right ventricle (RV), D-transposition of the great arteries (D-TGA), a perimembranous sub-aortic ventricular septal defect (VSD), and valvular and sub-valvular pulmonary stenosis. A Blalock–Taussig shunt was created in the neonatal period, followed by a Rastelli-type repair at the age of 7 years. The latter consisted of tunnelling left ventricular flow along the patch-repaired VSD to the aorta and directing RV flow to the pulmonary artery by means of a valved homograft. The native RVOT had not been over-sewn. At the age of 21 years, the patient presented with a haemodynamically tolerated VT consistent with RVOT origin. Despite treatment with Sotalol the patient experienced a second episode with pre-syncope. Investigations included echocardiography and cardiac magnetic resonance imaging. An electrophysiology study was undertaken of all medication under minimal sedation. A decapolar catheter was inserted into the coronary sinus and quadrapolar catheters were placed at the His bundle region and at the RV apex. Atrio-ventricular Wenkebach occurred at 340 ms with no aberrant conduction. No supraventricular tachycardia was inducible with atrial programmed electrical stimulation (PES; incremental …