An iatrogenic peri–left atrial appendage reentry after cryoisolation of a postsurgery left atrial appendage stump

Figures

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  Figure 1. A: Baseline 12-lead electrocardiography demonstrated tachycardia with a negative P-wave morphology in I and aVL, positive P-wave morphology in inferior leads, and positive P wave in V1 derivation. B, C: Three-dimensional mapping (Rhythmia; Boston Scientific, Marlborough, MA) showed the earliest activation to be in the distal portion of the left atrial appendage (LAA) stump (yellow arrow). C: Angiography of the LAA stump at right anterior oblique 30°. Dashed arrows indicate incomplete ligation; white arrow indicates LAA stump. D: LAA angiography which revealed the LAA stump. E: Ablation catheter in the LAA stump. F: Atrial tachycardia terminated mechanically during the operation.

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  Figure 2. A: Three-dimensional mapping (Rhythmia; Boston Scientific, Marlborough, MA) showed the earliest activation to be in the distal portion of the left atrial appendage (LAA) stump. B: LAA cryoballoon ablation angiography image: the complete occlusion of the LAA opening is shown with angiography at right anterior oblique 30°. C: Atrial tachycardia terminated during the cryoablation. D: After cryoablation, pacing in the LAA at a frequency of 400 ms could not capture the atrium, indicating the efferent block in the LAA and the electrical isolation of the LAA stump.

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  Figure 3. A: Electrocardiogram shows an atrial flutter with 2:1 AV conduction, with a short cycle length of 200 ms. B: The corresponding voltage map of the left atrium. C: Activation map: reentrant tachycardia around the left atrial appendage (LAA) through the channel between the prosthetic mitral valve and the LAA stump. There is an iatrogenic channel made by the cryoballoon that isolated the LAA stump (red double arrows). D: The last LAA cryoballoon ablation angiography image. E: Linear ablation was performed across the channel between the LAA and the mitral isthmus (red ablation points). F: During the linear ablation, tachycardia was terminated and converted to sinus rhythm.

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  Supplemental Figure 1. During the first surgery the CL of the tachycardia varied between 298-325ms.

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  Supplemental Figure 2. Between the LAA and mitral annulus, we did not found any abnormal potentials.