Repair Of Ventricular Septal Defect Research Articles

Postoperative Left Atrial Shunt in a Child with Ventricular Septal Defect Repair

Postoperative Left Atrial Shunt in a Child with Ventricular Septal Defect Repair

Surgical repair of post myocardial infarction ventricular septal defect: a retrospective analysis of a single institution experience

IntroductionVentricular septal defect (VSD) is a mechanical complication of acute myocardial infarction (MI) with a very high mortality, despite advances in surgical and circulatory support. The tremendous hemodynamic disturbance and the severely fragile myocardium render surgical repair a great challenge. The optimal time of surgical repair with or without circulatory support is still controversial.ObjectiveThe aim of this study is to review our experience with early surgical repair of post-MI VSD in a single major cardiac institution in China.MethodsFrom January 2013 to October 2020, 9consecutive patients presented to our emergency department with a diagnosis of post-MI VSD. Among them, 8 were male, and the mean age was 58 ± 7years. The mean VSD size was 22.5 ± 5.7 mm. In all patients, an intra-aortic balloon pump (IABP)was inserted immediately after admission to cardiac surgery service. All patients were operated at a mean of 3.3 ± 2.9 days, and 4 within 24 h of the rupture (range 1 to 9 days post-VSD). In 5 cases, the VSD was located superiorly, and 4 cases in the posterior septum.ResultsThe overall 30-day mortality was 11% (1/9). Coronary angiography was performed in all nine patients, four with single vessel disease had coronary stents implanted, and the other five received concomitant coronary artery bypass grafting during VSD repair surgery. There was no death in all 5 patients with anterior septal perforation. One patient with posterior septal perforation died in the operating room due to bleeding from the ventriculotomy site. Three survived patients were diagnosed with a small residual defect and mild left to right shunt post-repair. However, no further intervention was required, and patients remained asymptomatic (Killip II in 1 and III in 2).ConclusionIn our experience, immediate insertion of IABP and hemodynamic stabilization with early surgical intervention of VSD repair and concomitant coronary revascularization provided an 89% survival rate.

Repair of Ventricular Septal Defect in a Patient with Hemophilia A: Case Report

Hemophilia is an X-linked recessive hemorrhagic disease that affects 1 in 10,000 males worldwide, in all ethnic groups; hemophilia A represents 80% of all cases. Congenital heart disease is the most commonly occurring birth defect; it is formed during the intrauterine period. The combination of these two disease is rather rare and requires the cardiosurgeon’s apprehensive attitude. Here, we present our experience in the surgical treatment of a boy of 1-year-old with Perimembranous Ventricular Septal Defect with Hemophilia A which was found in preoperative examination. He was successfully operated with cardiac pulmonary bypass on the background of factor VIII injection.

Midterm prognosis following total correction of tetralogy of fallot in adult patients.

Tetralogy of Fallot is a common congenital heart disease characterized by cyanosis. The primary treatment approach involves corrective surgery typically performed within the first year of life to achieve complete resolution. However, certain patients may undergo surgery at an older age. This study seeks to assess the efficacy of surgery by examining the midterm outcomes of total correction of Tetralogy of Fallot when performed in older individuals. This interventional-longitudinal study focused on patients who underwent complete surgery to correct tetralogy of Fallot at an advanced age of over 15 years. All of the participants were referred to the Shahid Rajaei Heart and Vascular Center, which is a referral center for congenital heart diseases in Iran, between 2010 and 2020. The surgical procedures for these patients involved primary total correction of tetralogy of Fallot or surgery following by shunt implantation. Prior to the surgery, the necessary information was gathered from the patients' medical records. The patients were then monitored over a 5-year period, during which they received regular check-ups from cardiologist with fellowship in adult congenital heart disease. A total of 94 participants were enrolled in the study, with an average age of 26.7 ± 9.6 years. Notably, the majority of the participants were male. The study reported a late mortality rate of 3.2%. Furthermore, 17 patients, constituting 18% of the cohort, underwent a secondary surgical procedure. This secondary surgery encompassed 14 cases of Pulmonary Valve Replacement (14.8%) and 3 cases of Ventricular Septal Defect repair (3.1%). While the optimal age for total correction of Tetralogy of Fallot is conventionally considered to be within the first year of life, this study demonstrated that surgical intervention performed at a later stage of life can yield favorable midterm prognoses. It is imperative to emphasize that individuals unable to undergo surgery at the ideal age due to a multitude of factors should not be deprived of the potential benefits associated with surgical intervention.

THORACOSCOPY VERSUS STERNOTOMY IN THE CORRECTION OF A VENTRICULAR SEPTAL DEFECT: A SINGLE CENTER EXPERIENCE

Objective: To compare the immediate outcomes of thoracoscopy and median sternotomy in patients undergoing ventricular septal defect repair. Materials and мethods. We analyzed 59 patients diagnosed with VSD who were operated on at the SCCCST from 2012 to 2021. All patients were divided into two groups: group 1 included patients in whom thoracoscopic access was used (n=27), group 2 included the method of complete median sternotomy (n=32). Results. There were no statistically significant differences in complications in the postoperative period and no in-hospital mortality. The duration of the procedure and the duration of cardiopulmonary bypass in the thoracoscopy group were longer than in the sternotomy group. Blood loss during and after surgery was lower in the thoracoscopy group than in the sternotomy group. Hence, less blood and plasma transfusion was required in the thoracoscopy group than in the sternotomy group. The length of stay in the intensive care unit, the time spent on mechanical ventilation, bed days after surgery, the use of analgesics were statistically lower in the thoracoscopy group than in the sternotomy group. It should be noted that the length of the skin incision in patients in the thoracoscopy group was significantly less than in the second group. Conclusion. Thoracoscopic approach for VSD correction is an effective and low-traumatic method that does not increase the risk of surgical complications. Routine use of this technique requires a study on a larger sample of patients.

A Case of Duodenal Bleeding in a One-Year-Old Child in the Early Postoperative Period after the Surgical Correction of Congenital Heart Defect

Background. Gastrointestinal bleeding in children is a rather rare pathology. This especially applies to the bleeding in the postoperative period after surgical interventions that are not related to the pathology of the gastrointestinal tract. As a result, clinicians are not alert to the occurrence of such complications, which, in turn, can lead to late diagnosis and delay in the treatment of bleeding.
 Case report. We present a clinical case of duodenal bleeding in a one-year-old child in the early postoperative period after radical repair of ventricular septal defect by patching the defect. Laboratory parameters on admission: hemoglobin 120 g/L, red blood cells 4.37×1012/L. On the first postoperative day, hemoglobin was 103 g/L, hematocrit was 33%. On the 5th day after the operation, the boy had a currant jelly stool. Hemostatic therapy was provided: transfusion of fresh frozen plasma at a dose of 10 mL/kg, single administration of tranexamic acid at a dose of 10 mg/kg. The bleeding was stopped. After hemostatic therapy, hemoglobin was 105 g/L, hematocrit was 31%. Within 24 hours, fibrogastroduode-noscopy was performed which revealed an ulcer of the duodenal bulb covered with fibrin. The boy was consulted by gastroenterologist. Pathogenetic therapy was prescribed: proton pump inhibitors, antacids, enveloping drugs. The child was discharged home in a satisfactory condition on the 15th day after the operation under the supervision of a district pediatrician, cardiologist, and gastroenterologist. Laboratory parameters at discharge: hemoglobin 91 g/L, red blood cells 3.3×1012/L.
 Conclusion. The problem of gastrointestinal complications, including gastrointestinal bleeding in young children af-ter cardiac surgery, is extremely insufficiently covered in the scientific literature. Many questions remain unsolved re-garding the prevention, early diagnosis and treatment of bleeding, so research in this field remains relevant for both clinicians and scientists.

Comparing apples to apples: Exploring public reporting of congenital cardiac surgery outcomes based on common congenital heart operations

ObjectiveWe sought to simplify reporting of outcomes in congenital heart surgery that compares well-defined patient groups and accommodates multiple stakeholder needs while being easily understandable. MethodsWe selected 19 commonly performed congenital heart surgeries ranging in complexity from repair of atrial septal defects to the Norwood procedure. Strict inclusion/exclusion criteria ensured the creation of 19 well-defined diagnosis/procedure cohorts. Preoperative, procedural, and postoperative data were collected for consecutive eligible patients from 9 centers between January 1, 2016, and December 31, 2021. Unadjusted operative mortality rates and hospital length of stay for each of the 19 diagnosis/procedure cohorts were summarized in aggregate and stratified by each center. ResultsOf 8572 eligible cases included, numbers in the 19 diagnosis/procedure cohorts ranged from 73 for tetralogy of Fallot repair after previous palliation to 1224 for ventricular septal defect (VSD) repair for isolated VSD. In aggregate, the unadjusted mortality ranged from 0% for atrial septal defect repair to 28.4% for hybrid stage I. There was significant heterogeneity in case mix and mortality for different diagnosis/procedure cohorts across centers (eg, arterial switch operation/VSD, n = 7-42, mortality 0%-7.4%; Norwood procedure, n = 16-122, mortality 5.3%-25%). ConclusionsReporting of institutional case volumes and outcomes within well-defined diagnosis/procedure cohorts can enable centers to benchmark outcomes, understand trends in mortality, and direct quality improvement. When made public, this type of report could provide parents with information on institutional volumes and outcomes and allow them to better understand the experience of each program with operations for specific congenital heart defects.

Effective and aesthetic results of horizontal right axillary minithoracotomy for congenital heart defects repair in children

Background: horizontal right axillary minithoracotomy is one of the treatment options for many simple congenital heart defects. This approach shows many aesthetic advantages besides effectiveness and safety. This study aims to: comment on the technical characteristics and early results of horizontal right axillary minithoracotomy in children at Hanoi Heart Hospital.
 Methods: a descriptive cross-sectional study. We retrospectively reviewed 156 patients who underwent horizontal right axillary minithoracotomy at Hanoi Heart Hospital from January 2022 to December 2022.
 Results: horizontal axillary approach could be applied even for children with low weight, average weight was 12.22 ± 8.67 kg, the lowest was 2.6 kg and the highest was 51.0 kg. A wide range of congenital heart defects were repaired, including ventricular septal defect closure (84 patients), secundum atrial septal defect closure (22 patients), ventricular septal defect with stenosis repair (31 patients), partial atrio-ventricular septal canal repair (6 patients), repair of atrial septal defect with partial abnormal return of the pulmonary veins (3 patients), repair of ventricular septal defect and atrial septal defect (4 patients), Cor triatriatum sinister repair (4 patients), mitral valve repair (1 patient), atrial septal defect and pulmonary valve stenosis repair (1 patient). Cannulation of the aorta and vena cavae was performed through the main incision, whose size ranged from 3.5 to 5.5cm. The average postoperative hospital stay was 7.34 ± 2.16 days, the rate of severe complications and hospital mortality were 0%.
 Conclusion: horizontal right axillary minithoracotomy was a good approach to correct many simple congenital heart defects in children. This technique is being applied at Hanoi Heart Hospital safely and provided outstanding advantages in terms of aesthetics.

Minimally invasive surgical closure for ventricular septal defects through a horizontal right axillary minithoracotomy: early results at one center

Objectives: To investigate the early outcomes and cosmetic results of a horizontal right axillary minithoracotomy for closure of ventricular septal defects (VSDs) at Hanoi Heart Hospital.[1]
 Methods: a descriptive cross-sectional study. We retrospectively reviewed 119 children who underwent horizontal right axillary minithoracotomy for ventricular septal defects closure at Hanoi Heart Hospital from January 2022 to December 2022.
 Results: the average weight was 11.1 ± 8.2 kg, from 2.6 to 51.0 kg. The number of children below 6 months old accounted for 34.5% (41 patients). The rates of perimembranous VSD, infundibular VSD, inlet VSD, and muscular VSD were 68.1%, 27.7%, 3.4%, and 0.8%, respectively. The aortic cross-clamping time was 53.1 ± 23.5 minutes, the duration of cardiopulmonary bypass was 77.9 ± 29.7 minutes. The length of postoperative hospital stay was 7.4 ± 2.3 days. Postoperative residual shunt accounted for 5.9%, the rate of severe complications and hospital mortality were 0%.
 Conclusion: ventricular septal defects repair through a horizontal right axillary minithoracotomy at Hanoi Heart Hospital provided good early outcomes with satisfactory aesthetic results.

Infarct exclusion repair of postmyocardial infarction ventricular septal rupture with a hybrid patch and septal occluder device compared with patch only

ObjectiveWe developed a hybrid technique for repairing post-myocardial infarction (MI) ventricular septal defect (VSD) that combines infarct exclusion with patch and a nitinol-mesh septal occluder device (SOD) to provide a scaffold to support the damaged septal wall. Here, we compare outcomes of patients with post-MI VSD repaired using patch only or hybrid patch/SOD. MethodsPatients undergoing post-MI VSD repair at our institution from 2013 to 2022 who received patch alone or patch/SOD repair were analyzed. Primary outcome was survival to hospital discharge. Clinical outcomes and echocardiograms were also analyzed. ResultsOver a 9-year period, 24 patients had post-MI VSD repair at our institution with either hybrid patch/SOD (n = 10) or patch only repair (n = 14). VSD size was 18 ± 5.8 mm for patch/SOD and 17 ± 4.6 mm for patch only. In the patch/SOD repair cohort, average size of SOD implant was 23.6 ± 5.6 mm. Mild left ventricular dysfunction was present prerepair and was unchanged postrepair in both groups; however, moderate-to-severe right ventricular (RV) dysfunction was common in both groups before repair. RV function worsened or persisted as severe in 10% of hybrid versus 54% of patch-only patients postrepair. Tricuspid annular systolic excursion and RV:left ventricle diameter ratio, quantitative metrics of RV function, improved after patch/SOD repair. No intraoperative mortality occurred in either group. Postoperative renal, hepatic, and respiratory failure requiring tracheostomy was common in both groups. Survival to hospital discharge in both cohorts was 70%. ConclusionsPost-MI VSD repair with patch/SOD has comparable short-term outcomes with patch alone. Addition of a SOD to patch repair provides a scaffold that may enhance the repair of post-MI VSD with patch exclusion.

Long-term outcomes of percutaneous closure of ventricular septal defects in children using different devices: A single centre experience from Egypt

BackgroundThe feasibility of percutaneous closure ventricular septal defects (VSD) in children has been previously proven. However, data on long-term outcomes are limited. We aim to evaluate the long-term outcome of our experience with percutaneous closure of VSD using various occluders.MethodsRetrospective institutional analysis of children who underwent transcatheter closure of perimembranous and muscular VSDs between September 2012 and February 2020. Patient demographics, procedural, and long-term follow-up data were comprehensively analyzed. Patients who lost to follow-up within two years post-procedure were excluded.ResultsWe identified 75 patients (54.7% males) with a median of 66 months (IQR, 46–96). The closure success rate at one year was 95.7%. Complete heart block was detected in two patients early post-procedure and resolved with steroids. The VSDs were perimembranous (52%), muscular (33.33%), and residual (14.67%). Implanted devices were Pfm Nit-Occlud LeˆVSD Coil (42.7%), HyperionTM VSD Muscular Occluder (28%), Amplatzer VSD muscular occluder (10.7%), Amplatzer Duct Occluder (14.7%), Occlutech Muscular VSD Occluder (2.7%), and Amplatzer Duct Occluder II (1.3%). No new arrhythmia or valve regurgitation was detected after two years post-procedure. Persisted complications on long-term follow-up included: residual shunting in 3(4%), mild tricuspid regurgitation in 2(2.7%), and aortic regurgitation in 2(2.7%), with one immediate post-catheterization mild aortic regurgitation worsened during follow-up, requiring surgical repair of VSD three years after device implantation. No deaths were reported.ConclusionLong-term outcomes of pediatric transcatheter VSD closure using different devices are satisfactory. Post-procedural adverse events are limited, but long-term surveillance is necessary to monitor their progression.

Effect of Preoperative Volume Overload on Left Ventricular Function Recovery After Ventricular Septal Defect Repair

Significant left-to-right shunt across a ventricular septal defect (VSD) may lead to left ventricle (LV) volume overload and dilation. The acute loss of LV preload after repair of VSD may contribute to postoperative LV systolic dysfunction. The primary aim of the study is to assess the effect of presence of preoperative LV dilation on LV systolic function recovery after VSD repair. We evaluated the LV systolic function by measuring LV longitudinal strain and ejection fraction (EF) before surgery (time point 1) and at 5 time points after VSD repair (time point 2: 0 to 2 weeks, time point 3: 2 to 6 weeks, time point 4: 6 weeks to 4 months, time point 5: 4 to 12 months, and time point 6: >12 months). A total of 120 patients were included in the study cohort. A total of 84 patients (70%) had LV dilation (group 1) and 36 patients (30%) had normal LV size on preoperative echocardiogram (group 2). Median age (interquartile range 25% to 75%) at surgery was 5.5 months (4 to 10) and 7 months (5 to 44.5) in groups 1 and 2 respectively (p=0.03). Mean LV EF and strain were not significantly different among the 2 groups at time point 1. At time point 2, both mean EF and strain were significantly lower in group 1 compared with group 2 (p <0.05). At time point 3, mean EF was not significantly different among the two groups, while mean LV strain was significantly lower in group 1 (p=0.044). At time points 4, 5 and 6, mean EF and strain were not significantly different between the two groups. In conclusion, presence of preoperative LV dilation is associated with a more pronounced LV systolic dysfunction in the early postoperative period only. The LV systolic function recovers back to the baseline after the first year following the repair. These are very reassuring prognostic findings.

Shallow suture at ventricular septal defect may safely reduce right bundle branch block.

To avoid rhythm disturbance, sutures for ventricular septal defect closure have been traditionally placed 2∼5 mm or more away from the edge of the ventricular septal defect. However, the traditional suturing method appears to induce right bundle branch block and tricuspid valve regurgitation after ventricular septal defect closure more than our alternative technique, shallow suturing just at the edge of the ventricular septal defect (shallower bites at the postero-inferior margin). We aimed to verify our clinical experience of perimembranous ventricular septal defect repair. The alternative shallow suturing method has been applied since 2003 at our institution. We retrospectively reviewed the clinical data of 556 isolated perimembranous ventricular septal defect patients who underwent surgical closure from 2000 to 2019. We investigated the postoperative occurrence of right bundle branch block or progression of tricuspid regurgitation and analysed risk factors for right bundle branch block and tricuspid regurgitation. Traditional suturing method (Group T) was used in 374 cases (66.8%), and alternative suturing method (Group A) was used in 186 cases (33.2%). The right bundle branch block occurred more frequently in Group T (39.6%) than in Group A (14.9%). In multivariable logistic regression analysis, Group T and patch material were significant risk factors for late right bundle branch block. More patients with progression of tricuspid regurgitation were found in Group T. Shallow suturing just at the edge of the ventricular septal defect may reduce the rate of right bundle branch block occurrence and tricuspid regurgitation progression without other complications.

A case presentation of acquired membranous ventricular septum aneurysm as a rare delayed complication of ventricular septal defect repair surgery: 10-year follow-up

BackgroundRare as membranous ventricular septal aneurysms (MVSA) is, the possibility that occurs after ventricular septum defect (VSD) repair surgery is even more uncommon.PresentationA girl developed a MVSA 3 years after the VSD repair surgery at the age of 1 and increasing growth was noted during the follow-up. Aneurysm plication was carried done when she was 11 years old because it was observed to have a close relationship to the right coronary and obstructed the right ventricular outflow tract. Postoperative echocardiography follow-up revealed no abnormalities.ConclusionThough the prognosis of most patients with VSD repaired surgery was good, there remains varieties type of complications despite surgical advances. Accurate and rapid diagnosis of acute and delayed complications is essential to improve prognosis. In this case, the aneurysm was diagnosed by multiple imaging modalities and the girl underwent successful surgery again which provides direction for awareness and knowledge of delayed complications of VSD repair.

Successful Repair of Congenital Morgagni Hernia and Ventricular Septal Defect via Median Sternotomy in a Patient with Down Syndrome, Anal Atresia, Pectus Carinatum and Congenital Hypothyroidism

Successful Repair of Congenital Morgagni Hernia and Ventricular Septal Defect via Median Sternotomy in a Patient with Down Syndrome, Anal Atresia, Pectus Carinatum and Congenital Hypothyroidism

Evaluating variation in pre-operative evaluation and planning for children undergoing atrial or ventricular septal defect repair.

CHD care is resource-intensive. Unwarranted variation in care may increase cost and result in poorer health outcomes. We hypothesise that process variation exists within the pre-operative evaluation and planning process for children undergoing repair of atrial septal defect or ventricular septal defect and that substantial variation occurs in a small number of care points. From interviews with staff of an integrated congenital heart centre, an initial process map was constructed. A retrospective chart review of patients with isolated surgical atrial septal defect and ventricular septal defect repair from 7/1/2018 through 11/1/2020 informed revisions of the process map. The map was assessed for points of consistency and variability. Thirty-two surgical atrial septal defect/ventricular septal defect repair patients were identified. Ten (31%) were reviewed by interventional cardiology before surgical review. Of these, 6(60%) had a failed catheter-based closure and 4 (40%) were deemed inappropriate for catheter-based closure. Thirty (94%) were reviewed in case conference, all attended surgical clinic, and none were admitted prior to surgery. The process map from interviews alone identified surgery rescheduling as a point of major variability; however, chart review revealed this was not as prominent a source of variability as pre-operative interventional cardiology review. Significant variation in the pre-operative evaluation and planning process for surgical atrial septal defect/ventricular septal defect patients was identified. If such process variation is widespread through CHD care, it may contribute to variations in outcome and cost previously documented within CHD surgery. Future research will focus on determining whether the variation is warranted or unwarranted, associated health outcomes and cost variation attributed to these variations in care processes.

Postmyocardial Infarction Ventricular Septal Defect Repair With Perioperative Impella 5.5 Support

Postmyocardial Infarction Ventricular Septal Defect Repair With Perioperative Impella 5.5 Support

Staged definitive repair for pulmonary atresia and ventricular septal defect 40 years after palliative surgery: a case report

We present a very rare case of pulmonary atresia and ventricular septal defect with staged definitive repair more than 40 years after palliative surgery. The patient, a 43-year-old male, had undergone a Waterston operation at the age of one and had been untreated since then. Two years ago, he underwent an urgent surgery for impending rupture of a huge pulmonary artery aneurysm. Then, after evaluation of cardiac and pulmonary functions, a definitive repair was performed concomitantly with aortic root replacement for the dilated aortic root. He was discharged uneventfully and received ambulatory care 5 years after surgery.

Reduced length of stay after implementation of a clinical pathway following repair of ventricular septal defect.

There is variation in care and hospital length of stay following surgical repair of ventricular septal defects. The use of clinical pathways in a variety of paediatric care settings has been shown to reduce practice variability and overall length of stay without increasing the rate of adverse events. A clinical pathway was created and used to guide care following surgical repair of ventricular septal defects. A retrospective review was done to compare patients two years prior and three years after the pathway was implemented. There were 23 pre-pathway patients and 25 pathway patients. Demographic characteristics were similar between groups. Univariate analysis demonstrated a significantly shorter time to initiation of enteral intake in the pathway patients (median time to first enteral intake after cardiac ICU admission was 360 minutes in pre-pathway patients and 180 minutes in pathway patients, p < 0.01). Multivariate regression analyses demonstrated that the pathway use was independently associated with a decrease in time to first enteral intake (-203 minutes), hospital length of stay (-23.1 hours), and cardiac ICU length of stay (-20.5 hours). No adverse events were associated with the use of the pathway, including mortality, reintubation rate, acute kidney injury, increased bleeding from chest tube, or readmissions. The use of the clinical pathway improved time to initiation of enteral intake and decreased length of hospital stay. Surgery-specific pathways may decrease variability in care while also improving quality metrics.

PO-01-106 ATRIAL ISOCHRONAL LATE ACTIVATION MAPPING KEEPS THE DIAPHRAGM ALIVE

Isochronal late activation mapping (ILAM) is a well-established mapping method for ventricular arrhythmias. However, the role of ILAM mapping during atrial arrhythmias is less clear. This case provides an example of ILAM use during right atrial flutter ablation using the high-density Optrell (Biosense Webster, CARTO) catheter in a patient with congenital heart disease. N/A N/A A 27-year-old female with D-transposition of the great arteries status post Nikaidoh (arterial switch operation with ventricular septal defect repair, pulmonary valve replacement, and typical atrial flutter status post ablation presented with SVT and was referred for catheter ablation. During EPS, conventional activation mapping of fleeting atrial flutter was attempted utilizing the Optrell catheter, which localized the region of interest to a large section of the inferior posterolateral RA, which also had diffuse phrenic nerve capture (figure 1, panel A). However, during periods of sinus rhythm, ILAM and voltage mapping was conducted that demonstrated a distinct, confined, region of isochronal crowding along the mid-posterolateral right atrium, distant from the phrenic nerve (figure 1, panel B). The ILAM site was addressed with catheter ablation rendering the atrial flutter non-inducible with preservation of phrenic nerve function. The patient has remained free of atrial arrhythmias in the 6 months period since the ablation. The application of ILAM is well-established for ventricular tachycardia, however, its role in atrial arrhythmias is less clear. ILAM may be especially useful in adults with congenital heart disease given the complexity of atrial arrhythmia and the benefit of ablation in this unique population. Novel high-density mapping catheters, such as Optrell, allow for rapid and granular voltage data and translate well to ILAM regions within the atrium. Application of ILAM within atrial substrate, particularly for congenital heart disease which predisposes to higher recurrence rates, may improve both recurrence rates and safety, like in this case where the use of this method allowed avoiding ablation on the phrenic nerve.