Near-zero fluoroscopy ablation with a pulsed-field ablation system for persistent atrial fibrillation in a patient with a common inferior pulmonary vein

Figures

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  Figure 1. A: A 3D volume-rendering image of the LA created from contrast-enhanced CT. The LIPV and RIPV share a common trunk. B: An axial image from contrast-enhanced CT showing that the LIPV and RIPV form a common trunk, as indicated in A. The esophagus (green arrow) is observed adjacent to the LIPV. Additionally, the RIPV has a long diameter of approximately 10 mm but a short diameter of only 3 mm, suggesting a high risk for pulmonary vein stenosis. CT = computed tomography; LA = left atrium; LIPV = left inferior pulmonary vein; LSPV = left superior pulmonary vein; RIPV = right inferior pulmonary vein; RSPV = right superior pulmonary vein.

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  Figure 2. A: An image showing treatment based on the FAM created using the Octaray catheter. The image shows a wire inserted into the LSPV, with treatment being performed on the LSPV. The wire tip is indicated by the yellow arrow, and the PulseSelect catheter is represented by the blue arrow.B: An image taken after recording the treatment site of the LSPV with a snapshot, showing the wire being inserted into the LIPV for treatment of the LIPV. C: An intracardiac echocardiography image corresponding to B, showing the PulseSelect catheter deployed at the ostium of the LIPV. D: An image showing the catheter being moved to the RIPV for treatment while keeping the wire deployed in the LIPV. Given the flattened morphology of the RIPV, as described earlier, the wire insertion was deemed to be challenging. Treatment was deliberately performed using only the catheter without a wire insertion. E: Treatment of the RSPV after reinserting the wire into the RSPV. F: The post-ablation bipolar voltage map of the LA shows the electrical isolation of the pulmonary veins and posterior wall. The pulmonary veins and the posterior wall of the LA exhibit a low voltage (<0.2 mV). Additionally, the esophagus,…