Successful pulsed field ablation of left atrial roof-dependent atrial tachycardia arising after pericardial esophageal fistula

Figures

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  Figure 1. A: Radiofrequency catheter ablation guided by local impedance. Pulmonary vein isolation and linear ablation across the roof of the left atrium. B: The local impedance tracing demonstrated a rapid drop of >30 Ω within 5 seconds.

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  Figure 2. A: Contrast-enhanced computed tomography revealed pericardial effusion with air bubbles adjacent to the mid-esophagus (Eso), along with deformation of the posterior left atrial (LA) wall. The black arrow indicates deformation of the LA wall. The white arrow indicates air bubbles. B: Esophagography demonstrated extravasation of contrast and air into the oblique pericardial sinus, indicating that the fistula was located near the posterior carina of the left pulmonary veins. The right panel is a close up of the left panel. The white arrows indicate contrast leakage. Ao = aorta.

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  Figure 3. A: Activation map of roof-dependent atrial tachycardia involving a conduction gap from the previous radiofrequency ablation procedure. The critical isthmus exhibited larger omnipolar electrograms with the HD Grid catheter compared with the bipolar electrograms recorded with the PulseSelect catheter. The peak frequency at this site was 345 Hz. The green tag indicates the site of successful pulsed field application. B: Entrainment pacing at the critical isthmus from electrodes C1-C2 of the HD Grid catheter. Black arrows indicate low-amplitude fragmented potentials on the bipolar electrogram. The postpacing interval was equal to the tachycardia cycle length.

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  Figure 4. Termination of atrial tachycardia by the initial pulsed field application, with restoration of sinus rhythm. PFA = pulsed field ablation.

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  Figure 5. Voltage map after left atrial posterior wall isolation, demonstrating the absence of residual low-voltage areas and confirming complete posterior wall isolation.