Near-zero Fluoroscopic Approach for Laser Balloon Pulmonary Vein Isolation Ablation: A Case Study

Figures

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  Figure 1:. A: 3D geometry created of the RA, CS ostium, SVC, and IVC with multispline mapping catheter and 3D mapping system. Locations with PN capture during pacing are tagged on the wall of the SVC. B: View of the RA–SVC junction during advancement of the 0.032-in guidewire obtained with posterior flexion on the ICE catheter in the RA. C: EAM- and ICE-guided placement of the transseptal apparatus on the interatrial septum. D: Exchange wire placed within the LSPV on ICE. Ao: aorta; IAS: interatrial septum; TS: transseptal.

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  Figure 2:. A: LB catheter advanced directly into the LSPV under ICE visualization. B: LB inflated until the proximal side of the balloon is seen occluding the entire LSPV antrum. C: The inflated LB was pulled back into the LA cavity prior to repositioning in the LSPV for better occlusion. D: After finishing the ablation of the LSPV, the LB catheter was pulled back into the sheath. E: The sheath–catheter assembly is flexed and slightly clocked under ICE visualization until it was pointing toward the LIPV. F: Cannulation and inflation of the LB showed antral occlusion of the LIPV with the balloon.

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  Figure 3:. A: LB catheter with the tip of balloon positioned in the lower branch of the LSPV. The red arrow shows the green illuminated area from the beam aimed on the superoposterior wall. B: LB catheter with the tip of the balloon positioned in an upper branch of the LIPV. The red arrow shows the green illuminated area from the beam aimed on the posterior carina. C: 3D voltage map of the posterior LA and pulmonary veins prior to laser balloon ablation. D: Voltage map of the posterior LA and pulmonary veins acquired following laser balloon ablation. LAA: left atrial appendage.

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  Figure 4:. A and B: LB catheter advanced into the RIPV under ICE visualization after the “hockey-stick” maneuver and inflated to cover the antrum of the RIPV for ablation. C and D: After removing the LB catheter from the RIPV and adding posterior flexion to the ICE catheter, the sheath is undeflected and slightly clockwise rotated until the sheath–catheter assembly is seen in the same plane as the RSPV on ICE. The LB catheter is then advanced into the PV and inflated until the balloon is visualized occluding the antrum of a very large RSPV.