Ablate and pace as bail-out therapy in a patient with Fontan correction and malignant atrial tachycardia

Atrial tachyarhthmias complicating Fontan correction may have a 'malignant' clinical presentation seriously impairing the patient haemodynamic. Current strategies are surgical total cavopulmonary connection with or without antiarrhythmic surgery or transcatheter ablation. We describe the case of a patient who previously underwent atriocaval Fontan correction and later presented with refractory atrial tachycardia responsible for relapsing syncope. After a failed attempt at surgical conversion, and while waiting for heart transplantation, he was submitted to ablation of the atrioventricular node through an aortic retrograde approach and ventricular pacing through the coronary sinus tree. One year later, the patient is doing well, displaying a stable functional recovery and excellent pacing lead performances. An ablate and pace approach may deserve consideration in selected Fontan patients experiencing life-threatening atrial arrhythmias.