Management of pericardial bleeding complications in percutaneous endo-epicardial catheter ablation for atrial fibrillation: A case for intrapericardial tranexamic acid?

Figures

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  Figure 1. Epicardial access with CO2 insufflation technique over coronary vein exit in our patient. A,B: Coronary venogram in (A) right anterior oblique (large diverticula at coronary sinus os noted, orange arrow) and (B) left anterior oblique identifying suitable small side branch of a posterolateral branch (yellow arrow). C: Intentional coronary vein exit using a Confianza Pro wire (Asahi Intecc) (green arrows). D: Insufflation of 90 cc of CO2 over a micro-catheter and uncomplicated percutaneous subxiphoid puncture in 90° left lateral view on fluoroscopy (blue arrow pointing at needle). E: Insertion of steerable epicardial sheet in Seldinger technique and positioning of epicardial mapping catheter (white arrow) in pericardial space.

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  Figure 2. A: Posterior view on left atrial local activation time (LAT) map: Endocardial (top) and epicardial (bottom) LAT map with HD Grid (Abbott) during coronary sinus pacing, cycle length 600 ms. Posterior wall activated over slowly conducting epicardial connection on the roof, floor line blocked. Local electrogram in mid-posterior wall (red triangle) with significant delay of nearly 200 ms (white arrow) requiring extension of window of interest into QRS. B: View on left atrial roof (LAT). Top: Endocardial map with evidence of widely split double potentials (∼100 ms) on HD Grid splines positioned along roof line. Sparkles (green bright dots) indicate earliest activation of posterior wall occurs at right superior corner at site of insertion of septopulmonary bundle. Bottom: Epicardial map (full color) superimposed on endocardial map (black mesh) with evidence of long fractionated signals on opposing site to the earliest endocardial activation of the posterior box.

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  Figure 3. Left: Posterior view on endo-epicardial local activation time map (black line separating endo from superimposed epicardial map). Isolation of posterior box at right-sided roof line by endo-epicardial ablation (green points = ablation lesions). Start of bleed coinciding with positioning ablation catheter and delivering ablation lesions from epicardial site. Right: Anatomical model of left atrium demonstrating vascular network on roof/posterior wall (orange arrows). Dashed red lines indicating course of septopulmonary bundle, which was targeted for ablation. LIPV = left inferior pulmonary vein; LSPV = left superior pulmonary vein; RIPV = right inferior pulmonary vein; RSPV = right superior pulmonary vein.