Ablation of perimitral flutter in a patient with a partially inaccessible left atrium

Figures

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  Figure 1. Atypical flutter in a patient with a supra-annular mitral valve prosthesis. A: Electrocardiogram demonstrating an atypical flutter with variable atrioventricular block. B: Computed tomography and transthoracic echocardiography images demonstrating supra-annular implantation of the mitral valve prosthesis. LA = left atrium.

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  Figure 2. Left atrial catheter ablation with a supra-annular mitral valve prosthesis. A: Intracardiac echocardiographic image of the transseptal puncture and left atrium (LA). RA = right atrium. B: Endocardial LA voltage map and lesion set with Cartosound reconstruction of the ventricularized LA and mitral valve.

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  Figure 3. Vein of Marshall cannulation with a VisionWire (Biotronik) with entrainment. Fluoroscopic images demonstrate VisionWire cannulation of the vein of Marshall (red arrow). Entrainment from the VisionWire demonstrates the vein of Marshall is within the atrial flutter circuit. CS = coronary sinus.