Case Report
A 62-year-old female patient with paroxysmal atrial fibrillation, CHADS-VASc score 3, symptomatic despite treatment with propafenone, was referred for elective percutaneous ablation.
The procedure was performed under general anesthesia, after left appendage thrombus being discarded by transesophageal echocardiography. Triple femoral venipuncture was performed, flushed with 5,000 units of heparin. We positioned a standard deflective decapolar catheter across the coronary sinus. Transseptal puncture was performed in a conventional manner, guided by fluoroscopy, using right and left anterior oblique views. After first puncture, the sheath was advanced over the needle but no blood content was observed by lumen aspiration. We opted to advance a long guidewire to confirm that the sheath was inside the pericardial space (Figure 1). Due to maintained hemodynamic stability and absence of cardiac tamponade signs, we decided to insert a JR 6F angiography catheter in the pericardial space (Figure 2). Approximately 30 ml of citrine pericardial fluid was aspirated. At that moment, the hemodynamic condition remained stable and therefore we opted to resume the procedure. Another transseptal puncture was performed without complications while maintaining negative pressure through the JR catheter. Activated clotting time (ACT) levels were monitored and maintained above 300 seconds. Electroanatomical mapping (CARTO 3 – Biosense Webster Inc., Diamond. Bar, CA, USA) and circumferential isolation of the 4 pulmonary veins were performed (Figure 3). The isolation time was approximately 70 minutes.
After that, we proceeded with reversal of heparin levels with protamine, followed by withdrawal of both sheaths. The JR angiographic catheter was initially positioned in different points of the cardiac silhouette as aspiration continued to maintain the negative pressure (total time of aspiration of 20 minutes). Transthoracic echocardiogram inside the EP laboratory discarded pericardial effusion. Anticoagulation was resumed in the day after and the patient was discharged after 24 hours of observation. No late-onset complications or arrhythmia recurrence were noted during six months of clinical follow-up.