Catheter ablation for persistent atrial fibrillation in a patient with extensive lipomatous hypertrophy of the atrial septum: 3D electroanatomic mapping for ideal procedure planning and performance in abnormal atrial anatomy

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  Figure 1. Left anterior oblique (LAO) view in NavX EnSite X: 3-dimensional (3D) map of right atrium (RA) and left atrium (LA) created during atrial fibrillation and matched with the 3D anatomy gained from computed tomography data. A: Voltage map (voltage scale 0.05–0.5 mV). B: Corresponding segmentation of computed tomography data. C–F: LA pressure and fluoroscopy-guided transseptal puncture (TSP): an octopolar mapping catheter (Bard Electrophysiology EP XT) placed into the coronary sinus. The 3D electroanatomic map of the RA combined with biatrial computed tomography scan segmentation allowed placement of a standard quadrupolar ablation catheter (Flexability) into the supposed area of the fossa ovalis to mark desired location of TSP. LAO 45° fluoroscopic view (C) and right anterior oblique (RAO) 38° fluoroscopic view (D), both ahead of the pulldown maneuver of the TSP needle from the superior vena cava into the fossa ovalis. The aorta and coronary sinus catheter and spine served as anterior and posterior landmarks, respectively. The TSP needle, dilatator, and deflectable 8.5 (inner/11.7F outer diameter) sheath (Agilis) were then advanced into the LA. Fluoroscopic view after TSP from LAO…