Zero-fluoroscopy pulsed field ablation of atrial fibrillation in a patient with cor triatriatum sinister: a case report

Figures

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  Figure 1. Preablation imaging of the LA membrane and fenestration. A: Contrast-enhanced computed tomography showing the LA membrane. B: 3-dimensional reconstruction of contrast-enhanced computed tomography demonstrating the LA membrane. C: Transesophageal echocardiography identifying the LA membrane and fenestration (17.0 × 29.1 mm). Yellow and white arrows: LA membrane. AI-C = anteroinferior compartment; LA = left atrium; LAA = left atrial appendage; LIPV = left inferior pulmonary vein; LSPV = left superior pulmonary vein; PS-C = posterosuperior compartment; RIPV = right inferior pulmonary vein; RSPV = right superior pulmonary vein.

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  Figure 2. ICE and 3-dimensional imaging of cor triatriatum sinister. A: ICE from the right atrium showing the left atrial membrane attached to the anteroinferior fossa ovalis, forming a fenestration between the AI-C and the PS-C. B: Automated FAM of the LA generated from ICE. C: Transseptal puncture guided by ICE and 3-dimensional computed tomography. The first puncture entered the AI-C, whereas the second, targeted above the membrane, successfully accessed the PS-C. Yellow arrows: the LA membrane. Yellow star: Versacross radiofrequency wire. Blue arrows: the direction and position of the ICE imaging beam in the 3-dimensional mapping system. Pink triangle: first transseptal puncture site. Yellow triangle: second transseptal puncture site. AI-C = anteroinferior compartment; CECT = contrast-enhanced computed tomography; FAM = fast anatomic map; ICE = intracardiac echocardiography; LA = left atrium; LSPV = left superior pulmonary vein; PS-C = posterosuperior compartment; RA = right atrium.

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  Figure 3. 3-dimensional electroanatomic maps of the LA using the CARTO 3 system. A: Automated FAM of the LA merged with the manually created FAM of the membrane, demonstrating the PS-C, AI-C, and fenestration. B: Pre-PFA voltage maps during sinus rhythm. C: Post-PFA voltage maps showing complete pulmonary vein isolation. D: Post-PFA voltage maps overlaid with snapshots of each PFA application, showing concordance between application sites and lesion sets. AI-C = anteroinferior compartment; FAM = fast anatomic map; LA = left atrium; PFA = pulsed field ablation; PS-C = posterosuperior compartment.