Unintended Electrical Isolation of the Left Atrial Appendage due to Anatomical Misidentification During Pulsed‐Field Ablation: A Case Report

FIGURE 1. (A) Post‐procedural left atrial voltage mapping. The voltage map shows unintended isolation of the left atrial appendage (LAA) and inadvertent completion of the roof line. (B) The images show the sites where applications were delivered to the LAA using the basket and flower configurations. A retrospective analysis using the EnSite NavX system (Abbott Laboratories) revealed that the flower configuration applications to the LAA had been delivered more proximally than the left pulmonary veins. The basket configuration applications appeared to achieve better contact from the ridge to the roof of the left superior pulmonary vein. (C) The image shows the site where application was delivered to the left inferior pulmonary vein (LIPV) using the flower configuration. The flower configuration applications to the LIPV covered a wide area of the left pulmonary veins. AP, anterior–posterior; LAA, left atrial appendage; LAO, left anterior oblique; LIPV, left inferior pulmonary vein; PA, posterior–anterior.

FIGURE 2. Fluoroscopic images and voltage mapping 1 month after inadvertent isolation of the left atrial appendage (LAA). (A) A 10‐polar circular mapping catheter shows reappearance of LAA potentials. (B) Voltage mapping demonstrates resolution of LAA isolation and improvement of voltage in the roof area. RAO, right anterior oblique; Abbreviations are as above.

FIGURE 3. (A) Fluoroscopic image showing the relationship between the guidewire and the cardiac silhouette during attempted ablation of the left superior pulmonary vein (LSPV). During applications with both the basket‐ and flower‐type configurations, the guidewire appeared to remain within the cardiac silhouette without extending into a pulmonary vein branch. The arrowhead indicates the wire's course, and the black arrow indicates the cardiac silhouette. (B) Overlay image showing the positional relationship between the ring catheters placed at the ostia of the left atrial appendage (LAA) and LSPV. The LAA and LSPV are located in close proximity. PV, pulmonary vein; Abbreviations are as above.