An incessant atrial tachycardia originating from epicardial left atrial appendage in a 12-year-old girl: ablation or excision?
Atrial tachycardia (AT)—a rapid, irregular heartbeat starting in the heart’s upper chambers—is uncommon in children, but when it strikes, one unexpected culprit can be the left atrial appendage (LAA). This small, finger-like pouch attached to the left atrium is a known source of arrhythmias in adults, but AT arising from the epicardial (outer) surface of the LAA is especially rare in kids. For doctors, treating such cases requires balancing effectiveness with the unique risks of operating on a child’s delicate heart. A 2022 case report from Shanghai Jiao Tong University’s Xinhua Hospital offers a compelling solution: combining epicardial catheter ablation with surgical LAA removal to cure a 12-year-old girl’s drug-resistant AT.
The Case: A 12-Year-Old Girl’s Battle with Unrelenting Palpitations
The patient, a 12-year-old weighing 46 kg (101 lbs) and standing 165 cm (5’5”), had struggled with 5 months of persistent palpitations. Her electrocardiogram (ECG) revealed incessant AT—a fast rhythm (140–180 beats per minute) that wouldn’t respond to medication. Further tests showed her left atrium was enlarged (37 mm, above the normal <35 mm limit) and her NT-proBNP (a marker of heart stress) was sharply elevated (2586 pg/mL, vs. a normal <285 pg/mL). Her liver enzymes were also high, a sign the constant fast heartbeat was straining her body.
Doctors first tried endocardial catheter ablation (CA)—a standard procedure where a thin tube (catheter) is threaded through blood vessels to the inner surface of the heart, delivering radiofrequency energy to destroy faulty tissue triggering the arrhythmia. But the LAA’s structure derailed this attempt: its maze of trabeculations (muscle ridges) and thin walls made it impossible to safely reach the abnormal tissue without risking life-threatening perforation or tamponade (fluid buildup around the heart). The endocardial ablation failed to stop the AT.
A New Approach: Epicardial Ablation + Surgical Appendectomy
Faced with limited options, the team turned to an epicardial approach—accessing the outer surface of the heart through a small chest incision. Under general anesthesia and single-lung ventilation (to better visualize the heart), surgeons opened the left pericardium (the sac surrounding the heart) and mapped the LAA’s outer surface. They found the earliest activation of the AT—120 milliseconds before the rhythm’s peak—at the apex of the LAA’s upper lobe.
Using an irrigated ablation catheter, they delivered radiofrequency energy to this spot. Within 5 seconds, the AT stopped. To prevent recurrence (a known risk with LAA ablation, given the pouch’s fragile structure), they followed with surgical left atrial appendectomy (SAE)—removing the LAA entirely. The procedure took 90 minutes with no complications.
Results: A Year of Normal Heartbeats and Improved Health
Seven days later, the girl’s heart had already begun to heal: her left atrium shrank to 29 mm (normal size), her NT-proBNP dropped to 133 pg/mL (normal), and her liver enzymes returned to healthy levels. Twelve months after the procedure, she remained free of palpitations or arrhythmias—a “cure” that would have been impossible with medication alone.
Why This Matters for Kids with LAA-Related AT
The LAA is a relic of embryonic development, but its thin walls and complex anatomy make it a high-risk target for ablation—especially in children, where the heart is smaller and more fragile. For this patient, the combination of epicardial ablation (to precisely target the faulty epicardial tissue) and SAE (to eliminate the LAA entirely) offered a balanced risk-benefit ratio: it stopped the AT and removed the source of future arrhythmias.
While endocardial ablation is the first-line treatment for most pediatric AT cases, this report highlights that epicardial access can be a lifeline when the LAA is involved. The team noted that surgical appendectomy is particularly valuable for kids with incessant (non-stop) AT, as repeated ablation attempts risk perforation or scarring.
What’s Next?
This case is rare—few studies have documented epicardial LAA AT in children—but it provides a roadmap for doctors facing similar challenges. The girl’s 12-month success is promising, but long-term research is needed to confirm whether SAE is safe for kids as they grow. For now, though, her story offers hope: even when standard treatments fail, tailored approaches combining ablation and surgery can restore normal heart rhythm—and normal life—for young patients.
Xiangfei Feng, Qunshan Wang, Jian Sun, Pengpai Zhang, Yi Yu, and Yigang Li from the Department of Cardiology at Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, published this case in the Chinese Medical Journal in 2022.
doi.org/10.1097/CM9.0000000000001778
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