From mapping to clipping: The role of thoracoscopic left atrial appendage clipping in refractory focal left atrial tachycardia

Figures

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  Figure 1. 12-lead electrocardiogram demonstrating atrial tachycardia with a ventricular rate of 97 beats per minute. Positive P wave in V1, bifid P wave in lead II, negative P wave in lead I localize the focus of tachycardia to either the left atrial appendage or the left pulmonary vein as per the Kistler algorithm.

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  Figure 2. Local activation time map of the left atrium created during atrial tachycardia using the EnSite system. A: Anterior view. B: Posterior view. The earliest activation site (red) is located at the distal tip of the left atrial appendage with centrifugal propagation toward the rest of the left atrium.

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  Figure 3. Voltage map of the left atrium using the EnSite system. A: Anterior view. B: Posterior view. The map demonstrates a relatively healthy left atrium.

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  Figure 4. Surgical clip used in left atrial appendage occlusion. A: Open position. B: Closed position.

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  Figure 5. Intraoperative thoracoscopic views of left atrial appendage (LAA) clipping. A: Preclosure: the LAA was visualized, and the surgical clip was positioned at its base. B: Postclosure: the LAA is completely excluded with the clip securely in place across its base.

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  Figure 6. Axial computed tomography cardiac angiogram before and after left atrial appendage (LAA) closure. A: Preclosure: the LAA is well opacified with contrast, indicating normal blood flow. B: Postclosure: a radiopaque clip is visible at the LAA ostium with no contrast filling, consistent with successful LAA exclusion.

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  Figure 7. Oblique coronal computed tomography cardiac angiogram demonstrating left atrial appendage (LAA) closure. A: Postclosure: a radiopaque surgical clip is seen at the LAA ostium with complete absence of contrast opacification, confirming successful exclusion. B Preclosure: the LAA is fully opacified with contrast, demonstrating patency and communication with the left atrium.