Clinical case
A 64-year-old male was admitted to the cardiology department of our
hospital to undergo catheter ablation of longstanding persistent AF and
simultaneous LAA closure.
His past medical history was notable for a bi-hemispheric stroke seven
years earlier, for which he received systemic thrombolysis. At the time,
the 12-lead ECG revealed a first-diagnosed AF, while the echocardiogram
was normal. He was prescribed warfarin and did well for 5 years; two
attempts with electrical cardioversion to restore sinus rhythm have been
tried without success during these years. However, in the last two
years, there were multiple recurrences of transient ischemic attack
(TIA) and ischemic stroke despite adequate anticoagulant therapy
(warfarin first, then dabigatran and rivaroxaban). The other possible
causes of ischemic recurrences (carotid artery disease, patent foramen
ovale, systemic thrombophilias) were all excluded.
To save time during the ablation phase of the procedure, we decided to
use PFA. The procedure was carried out under general anaesthesia and
oro-tracheal intubation, with uninterrupted oral anticoagulation with
rivaroxaban and intravenous heparin bolus (than continued infusion)
right before transseptal puncture. TEE monitoring was performed during
the procedure, and revealed an intense smoke effect in the left atrium
(LA) and LAA (Figure 1); accordingly, the right radial artery was
accessed using the Seldinger technique, and a GLIDESHEATH SLENDER
hydrophilic coated introducer sheath (Terumo Medical Corporation,
Somerset, NJ) was inserted into the vessel. Next, the
SENTINELTM cerebral protection device was advanced to
the aortic arch and positioned at the level of the brachiocephalic and
left carotid arteries under fluoroscopy guidance (Figure 1).
The intracardiac echocardiography (ICE) (ACUSON AcuNav Ultrasound
Catheter, Siemens) was placed through the femoral vein into the right
atrium to facilitate transseptal puncture, check the contact between the
ablation catheter and the pulmonary vein (PV) antrum, and assist the
procedure.
A single transseptal puncture was performed and the PFA sheath was
introduced into the LA. Then, the ablation catheter (Farawave, Pulsed
Field Ablation catheter) was advanced in LA.
The Farawave catheter has 5 splines, each containing 4 electrodes, and
it can be deployed in either a flower petal or basket configuration. For
the biphasic waveforms, the generator output is set at 2,000 V per
application.
The catheter was rotated between applications to ensure coverage of the
entire antrum and ostia of each PV. ICE imaging and fluoroscopy were
used to optimize PFA catheter positioning at the PV ostia (Figure 2).
For each PV, 4 two-second applications were delivered in basket
configuration and 4 in petal flower configuration; after completion, the
antral electrical isolation of the 4 PVs was confirmed by documenting
exit block by pacing maneuvers. Finally, sinus rhythm was restored by
electrical cardioversion with single 200J synchronized shock.
Afterwards, a double-curve WATCHMAN access sheath was introduced into
the LA under continuous TEE and ICE monitoring. A 24 mm LAA closure
device (WATCHMAN FLXTM) was successfully deployed in
the LAA with a single attempt, without dislocation. No leakage was
documented at the TEE and fluoroscopy check (Figure 3). At the end of
the procedure, the cerebral protection device was successfully retracted
and one little thrombus was noted to be collected within the SENTINEL
device (Figure 3). The patient was extubated and awoke from anesthesia
without any neurologic deficits or evidence of systemic thromboembolism.