Rescue percutaneous coronary intervention for sinus node dysfunction following left atrial flutter ablation

Figures

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  Figure 1. The voltage and activation map of the tachycardia and ablation points. A: The voltage map of the left atrium (LA) showed a broad low-voltage area at the anterior wall of the LA during sinus rhythm. B: The activation map showed tachycardia as a perimitral flutter. An anterior block line was performed between the mitral annulus and the right pulmonary vein (red tag). Additional radiofrequency application (black arrow) was delivered near the ostium of the LA appendage.

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  Figure 2. The contrast between coronary computed tomographic angiography (CCTA) or coronary angiography and the 3-dimensional map of the left atrium (LA). A: Volume-rendered view of CCTA showing occlusion of the sinus nodal artery (black arrow) originating from the left circumflex artery (LCX). B: The fusion of CCTA showing the left coronary artery and the anatomical shell of the LA is presented. The sinus nodal artery (white arrow) was occluded near the ablation point of the left atrial anterior wall (red tag). C: Coronary angiography showed an occluded sinus nodal artery (white arrow) originating from the LCX. D: The fusion of CCTA showing the left coronary artery and the anatomical shell of the LA is presented. The sinus nodal artery (white arrow) was occluded near the ablation point of the left atrial anterior wall (red tag). Ao = aorta; LAA = left atrial appendage; LAD = left anterior descending artery; LIPV = left inferior pulmonary vein; LSPV = left superior pulmonary vein; PA = pulmonary artery; RA = right atrium; RIPV = right inferior pulmonary vein; RSPV = right superior pulmonary vein.

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  Figure 3. Percutaneous coronary intervention (PCI) for the occluded sinus nodal artery. A: Pre-PCI coronary angiography (CAG) showing the occluded sinus nodal artery (white arrow) originating from the left circumflex coronary artery (LCX). B: Plain old balloon angioplasty (POBA) using semi-compliant balloon (diameter = 1.5mm) for the occluded sinus nodal artery. White arrowheads indicate balloon-treated sites. C: Post-PCI CAG showing the recanalized sinus nodal artery (yellow arrowheads). D: Pre-PCI intravascular ultrasound (IVUS) cross-section showing the occluded lesion of the sinus nodal artery (corresponding with white arrow in panel A). The vessel diameter was approximately 1.5 mm and the lumen was invisible. The perimedial high-echoic band was partially identified (yellow arrows), while the vessel structure (3 layers of the vessel) on the left atrium (LA) side could not be clearly identified (red arrowheads). The orientation of the LA side was determined based on the location of the small side branches of the sinus nodal artery also identified on angiography. E: Post-PCI IVUS cross-section showing the recanalized lumen of the sinus nodal artery (corresponding with white arrow in…