Minimally invasive videoscope-assisted cardiac surgery for paroxysmal atrial tachycardia originating from right atrial appendage

A 35-year-old female complained about palpitations for over 2 years and was admitted to department of cardiology. The 12-lead electrocardiogram (ECG) and 24 h Holter monitoring revealed the paroxysmal supra-ventricular tachycardia (Panel A). No structural abnormalities or impaired ventricular function were detected by transthoracic echocardiography, transoesophageal echocardiography, or multi-slice computed tomography. The tachycardia was not terminated after transcatheter radiofrequency ablation in the base and middle of right atrial appendage (RAA). Electro-anatomical three-dimensional mapping system (Carto) demonstrated that the earliest endocardial breakthrough was on the apex of RAA (Panels B and C, Supplementary material online, Video S1) and confirmed the diagnosis of the paroxysmal atrial tachycardia (PAT). Considering the high risk of RAA rupture by ablation, the patient was transferred to the department of cardiovascular surgery for ligation of RAA under videoscope-assisted cardiac surgery. During the surgery, a thin-walled cyst-like structure was found deriving from the RAA (Panels D–G, star). Not surprisingly, the rhythm immediately returned to sinus right after test clamping the cyst by a right-angle clamp (Panel D, Supplementary material online, Video S2). Finally, the left atrial appendage clip (E-clip) was deployed (Panels E–G) to isolate the structure. The postoperative ECG indicated sinus rhythm with the rate of 75 beats per minute (Panel H).