Combined transhepatic and transjugular approach for radiofrequency ablation of an accessory pathway in a child with complex congenital heart disease.

We report on a boy with recurrent drug resistant atrioventricular reentrant tachycardia. The patient had complex structural heart disease consisting of right atrial isomerism, systemic venous anomaly (mirror image orientation of the intrathoracic veins, hemiazygos continuation to the left-sided superior vena cava, with separate drainage of the hepatic veins into the left-sided atrium, congenitally corrected transposition (ccTGA), pulmonary atresia (PA), ventricular and atrial septal defects (VSD and ASD). At the age of 22 months RF ablation was performed. Access to the heart was obtained by percutaneous puncture of a hepatic vein, the left internal jugular vein, and femoral artery. Earliest retrograde atrial conduction during tachycardia was localized to the free wall of the left-sided AV groove, and ablation in this area was successful. There were no procedure-related complications. RF ablation of accessory pathway is feasible in young children with complex structural heart disease and abnormal systemic venous return. In such patients access to the heart must be planned with the knowledge of the anatomy and judicious use of the hepatic venous approach, which should be done only by experienced investigators.