Multimodality Imaging‐Guided Pulsed Field Ablation for Atrial Fibrillation in Cor Triatriatum Sinister

Figures

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  FIGURE 1. Echocardiographic findings. Transthoracic echocardiography demonstrates the division of the left atrium (LA) into an accessory chamber (AC) and a main chamber (MC) by a fibromuscular membrane. A discrete fenestration is visible within the membrane (arrowheads). AC, accessory chamber; LA, left atrium; LV, left ventricle; MC, main chamber; RA, right atrium; RV, right ventricle.

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  FIGURE 2. Multi‐detector computed tomography (MDCT) findings. (a) Coronal MDCT image of the LA (right) with corresponding numbered axial sections (left). (b) Three‐dimensional reconstruction showing all pulmonary veins (PVs) draining into the AC. (c) Three‐dimensional reconstruction with a superior inner view demonstrates that the LA is partitioned by a membrane containing two fenestrations. AC, accessory chamber; LA, left atrium; LAA, left atrial appendage; LS, left superior; LI, left inferior; MC, main chamber; PV, pulmonary vein; RS, right superior; RI, right inferior.

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  FIGURE 3. Intracardiac echocardiography (ICE) and image integration. (a) ICE view of the right ventricular outflow tract toward the LA. The LA and membrane (orange arrowheads) were mapped from the right ventricular outflow tract and RA and then merged with the CT‐derived anatomy. (b) Before transseptal puncture, the transseptal needle tens the fossa ovalis toward the AC. (c) After transseptal puncture, the guidewires (blue arrowheads) were advanced into the AC through the fossa ovalis (FO). (d) After sheath entry into the LA, additional ICE imaging was performed from the LA side to refine the merged image. (e) LA voltage maps during RA pacing. Anteroposterior (AP) and posteroanterior (PA) views are overlaid on the LA angiogram. The voltage was color‐coded from red (low) to purple (normal). AC, accessory chamber; AO, aorta; AP, anteroposterior; FO, fossa ovalis; ICE, intracardiac echocardiography; LA, left atrium; LAA, left atrial appendage; LS, left superior; LI, left inferior; MC, main chamber; PA, posteroanterior; PV, pulmonary vein; RA, right atrium; RS, right superior; RI, right inferior.

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  FIGURE 4. Post‐ablation voltage maps. (a) Post‐pulsed‐field ablation (PFA) LA voltage map. Purple dots and lines indicate the PFA application sites. The positions of the VARIPULSE catheter and sheath during ablation of each PV are annotated. The voltage was color‐coded from red (low) to purple (normal). (b) The PA‐view LA voltage map during RA pacing after PFA was overlaid on the LA angiogram. AC, accessory chamber; LA, left atrium; LS, left superior; LI, left inferior; MC, main chamber; PA, posteroanterior; PFA, pulsed‐field ablation; PV, pulmonary vein; RA, right atrium; RS, right superior; RI, right inferior.