Left atrial intramural hematoma during radiofrequency catheter ablation for atrial fibrillation: The important role of intracardiac echocardiography

Figures

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  Figure 1. Electroanatomic CARTO3 Mapping System (Biosense Webster, Diamond Bar, CA) showing reconnection of the left pulmonary veins.

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  Figure 2. Intracardiac echocardiography showing calcification of the mitral isthmus at the inferior lateral region, extending to the left atrial posterior wall, close to the left inferior pulmonary vein ostium floor. abla = ablation catheter; DESC AO = descending aorta; LA = left atrium; LASSO = circular catheter; LIPV = left inferior pulmonary vein.

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  Figure 3. A significant steam pop (yellow arrow) occurred instantly during the first third of the inferior line, close to the calcification.

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  Figure 4. Intracardiac echocardiography showed an image formation, heterogeneous, filled with layers, suggesting a dissection within the left atrium posterior wall, extending between the inferior pulmonary veins (yellow arrows).

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  Figure 5. Color Doppler detected a low-velocity blood flow inside the image formation, and a 2.4-mm entering orifice was visualized (yellow arrow).

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  Figure 6. Electroanatomic CARTO3 (Biosense Webster, Diamond Bar, CA) LA remapping showing (A, B) linear lesions with the application data from the steam pop and location and the hematoma under CARTOSOUND Module (Biosense) visualization and (C, D) remapping showed completed posterior wall and posterior wall isolation. Yellow arrow: intramural hematoma (on CARTOSOUND Module).

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  Figure 7. Computed tomography scans performed on the first day after the procedure, confirming the diagnosis of intramural hematoma (yellow arrows). No blood flow was noted in the late contrast-enhanced computed tomography images. Two-chamber (A) and 4-chamber (C) views pre contrast when the hematoma has increased density. Two-chamber (B) and 4-chamber (D) views post-contrast images when the hematoma shows reduced density and its relationship with the left atrium.

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  Figure 8. Computed tomography scans performed 3 months after the procedure showed total regression of the hematoma. Two-chamber (A) and 4-chamber (C) views precontrast. Two-chamber (B) and 4-chamber (D) views postcontrast images.