Case Report
A 68-year-old male was referred to our centre for a primary AF and
atrial flutter (AFL) ablation. His past medical history included
dyslipidaemia and a previous interstitial pneumonia SARS-CoV-2 related,
complicated by bilateral pulmonary embolism and typical atrial flutter,
treated by pharmacological cardioversion. Since hospital discharge the
patient has suffered from frequent atrial fibrillation episodes, as
documented by multiple smartwatch ECG registrations. Laboratory blood
investigations showed the following: hemoglobin, 15,8 g/dL; white cell
count, 7.8 x 109/L; sodium, 143 mmol/L; potassium, 4.0
mmol/L; urea, 27 mg/dL; and creatinine, 0,8 mg/dL. An echocardiogram
documented normal biventricular size and function with normal left
atrial dimensions and normal valvular function. As patient’s
CHA(2)DS(2)-VASC was 1, according to our internal protocol, a
transesophageal echocardiography was not performed. The procedure was
made under uninterrupted anticoagulation with edoxaban. The patient
provided written informed consent prior to the ablation procedure. The
electrophysiological procedure was performed in deep sedation. After
obtaining ultrasound-guided 2 left and 1 right femoral venous
access5, a decapolar diagnostic catheter (Dynamic
XTTM, Boston Scientific) was placed into coronary
sinus (CS) and a steerable quadripolar diagnostic catheter (Dynamic
TIPTM, Boston Scientific) was placed into the right
ventricle. A 0.032 J-tip guidewire was placed from the right femoral
access site to the superior vena cava (SVC). The AcQCross™️ Qx system
combined with Medtronic FlexCathTM Advance steerable
sheath was placed over the guidewire to the SVC. The AcQCross™️ Qx
system was then connected to a pressure line by an Y connector (Fig.1A).
After retracting the guidewire to the tip of the dilator, the sheath was
pulled back caudally until an abrupt leftward movement (jump) of the tip
below the aortic knob is observed (in the postero-anterior view) as the
tip passes under the muscular atrial septum onto the fossa ovalis. After
confirming the position of the tip in RAO and LAO view, the slider
button was advanced forward on the AcQCross™️ Qx proximal handle,
inducing the protrusion of the hollow stainless steel needle and
resulting in effective puncture of the fossa ovalis (Fig.2A), as
confirmed at first by the pressure line which showed LA pressure
(Fig.1B). Thereafter the retained guidewire was easily advanced into LA
and placed distally into the left superior pulmonary vein (Fig.2B) and
finally the steerable sheath was advanced into the LA over the wire
(Fig.2C-D). In this case the delivery of radiofrequency via the needle
in order to puncture the septum was not necessary. The cryoballoon was
then advanced without any need of sheat exchange and a conventional
pulmonary vein isolation (PVI) with single application of cryoenergy for
240 sec per vein was performed. After PVI and during proximal CS pacing,
an ablation index-guided cavotricuspid isthmus ablation with point by
point lesions using 3D mapping (Carto 3, Biosense Webster) was
performed. At the end of procedure an echocardiogram documented absence
of pericardial effusion. The procedural data are displayed in Table 1.
On the same evening of procedure an echocardiogram documented absence of
pericardial effusion. On the next day after a clinical evaluation the
patient was discharged. A follow-up with Holter ECG and medical
evaluations at 3, 6 and 12 months from the ablation was scheduled.