Pulmonary vein isolation using a novel balloon-in-basket pulsed field ablation system: The Lübeck how-to protocol

Figures

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  Figure 1. Balloon-in-basket (BiB) preparation and introduction protocol. A and B: Balloon preparation and preinflation to verify integrity and eliminate residual air. C and D: Advancement of the introducer aid over the balloon while submerged under water to ensure complete deairing and smooth assembly. E and F: Introduction of the BiB catheter through the steerable sheath under continuous saline infusion to maintain positive pressure and prevent air ingress.

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  Figure 2. Balloon-in-basket (BiB) positioning and ablation of the LSPV. A and B: Advancement of the BiB catheter into the LSPV by withdrawal of the steerable sheath. C: Balloon inflation with 9 mL saline and 1 mL contrast. D: Energy delivery after confirmation of stable tissue contact (blue indicator = ≥2/3 electrode contact). E and F: Catheter rotation for the second ostial application to achieve circumferential coverage. LAO = left anterior oblique; LSPV = left superior pulmonary vein.

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  Figure 3. Access to the right superior pulmonary vein (RSPV). A and B: Sheath deflection (∼30°) and clockwise rotation under LAO fluoroscopy to align toward the RSPV. C and D: Wire advancement into the RSPV followed by balloon-in-basket catheter advancement and inflation. LAO = left anterior oblique.

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  Figure 4. Access to the right inferior pulmonary vein (RIPV). A and B: Partial balloon retraction into the sheath. C and D: Increased sheath deflection (∼45°) with minimal counterclockwise rotation. E and F: Guidewire placement into the RIPV followed by balloon advancement, inflation, and positioning at the ostium.

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  Figure 5. Posterior wall isolation using the balloon-in-basket catheter. The catheter is positioned along the left atrial posterior wall, and splines without adequate tissue contact are selectively deselected to optimize lesion delivery. A: Electroanatomic map during posterior wall ablation. B: Postablation electroanatomic map demonstrating posterior wall isolation. C: Corresponding fluoroscopic image in right anterior oblique 30° projection. D: Corresponding fluoroscopic image in left anterior oblique 40° projection.

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  Figure 6. Learning curve displayed by procedural duration. Individual procedural durations for all 40 patients. Bars represent procedural time in minutes for each consecutive case. Patients who underwent PVI plus posterior wall ablation are shown in red, whereas patients who underwent PVI alone are shown in blue. PVI = pulmonary vein isolation.