How to Perform a Completely Fluoroless Ablation

Figures

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  Figure 1:. Electroanatomic map of the right atrium, superior vena cava, inferior vena cava, His bundle, and coronary sinus in a patient undergoing ablation of the slow pathway.

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  Figure 2:. (A) An intracardiac echocardiography shell of the left atrium and its structures, which was used as a reference to construct (B) an electroanatomical map using the multipolar catheter after the transseptal puncture. Abbreviations: LIPV, left inferior pulmonary vein; LSPV, left superior pulmonary vein; RIPV, right inferior pulmonary vein; RMPV, right middle pulmonary vein; RSPV, right superior pulmonary vein.

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  Figure 3:. Fluoroless visualization of a multipoint, sinusoidal esophageal temperature probe (CIRCA S-CATH) using intracardiac echocardiography. The temperature spread can confirm the proper insertion depth; the esophageal temperature is lower on the proximal electrodes (10–12) closer to the trachea above the left atrium.

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  Figure 4:. Intracardiac echocardiography image showing the J-tip wire in the superior vena cava. Abbreviation: SVC, superior vena cava.

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  Figure 5:. Intracardiac echocardiography showing the steps for a successful transseptal puncture. The transseptal system (sheath, dilator, and needle) is gradually withdrawn while maintaining the needle in the 4 o’clock position. A drop is typically felt after (A) the superior limbus of the interatrial septum has been reached, and another one is noted at the level of the fossa ovalis. B: The needle is then advanced to ensure “tenting” as it is exposed. Once the transseptal puncture has been performed, left atrial pressure is obtained to ensure safe placement. The needle is then held in place while (C) the dilator is advanced over it before (D) being exchanged for a ProTrack pigtail wire, as indicated by the asterisk. The arrow in (C) points to the aorta.

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  Figure 6:. Proper Achieve catheter positioning using the electroanatomic map in the (A) left superior, (B) left inferior, (C) right inferior, and (D) right superior pulmonary veins.

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  Figure 7:. Proper cryoballoon positioning using intracardiac echocardiography in the (A) left superior, (B) left inferior, (C) right inferior, and (D) right superior pulmonary veins. Asterisk indicates the right pulmonary artery, which typically comes into view while visualizing the right superior pulmonary vein.

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  Figure 8:. Pressure tracing during cryoablation: once the pulmonary vein is occluded, the pressure curve changes from a left atrial pressure curve to a pulmonary artery pressure curve.

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  Figure 9:. Electroanatomic map in a patient undergoing right ventricular outflow tract tachycardia ablation. Abbreviations: IVC, inferior vena cava; SVC, superior vena cava.

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  Figure 10:. Electroanatomic map in a patient undergoing left ventricular tachycardia ablation. The map was guided by an ultrasound shell created earlier using intracardiac echocardiography.

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  Figure 11:. Intracardiac echocardiography image showing an atrial lead in the right atrial appendage. Abbreviation: RAA, right atrial appendage.

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  Figure 12:. Incorporation of the course of the right atrial lead as shown on intracardiac echocardiography (Figure 11) into the electroanatomic map. Abbreviation: ICE, intracardiac echocardiography.