Successful fluoroless ablation of an incessant atypical atrial flutter attributed to AtriClip usage during mini-MAZE surgery for persistent atrial fibrillation

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Successful fluoroless ablation of an incessant atypical atrial flutter attributed to AtriClip usage during mini-MAZE surgery for persistent atrial fibrillation Xiaoke Liu, MD, PhD, Jerry Pratt, MD, James Palmer, NP HeartRhythm Case Reports Volume 3, Issue 7, Pages 352-356 (July 2017) DOI: 10.1016/j.hrcr.2017.05.004 Copyright © 2017 Heart Rhythm Society Terms and Conditions

Figure 1 Complete isolation of the left atrial posterior wall during persistent atrial flutter. A: Demonstration of complete loss of electrogram on the Lasso catheter placed over the posterior wall. B: Position of the circular Lasso and ablation catheters at the time of posterior wall isolation, shown on the CARTO mapping system. LAO = left anterior oblique; RAO = right anterior oblique. HeartRhythm Case Reports 2017 3, 352-356DOI: (10.1016/j.hrcr.2017.05.004) Copyright © 2017 Heart Rhythm Society Terms and Conditions

Figure 2 Entrainment and successful termination of the atypical atrial flutter during ablation. A: Examples of complex electrograms, including fractionated (1), split (2), and very low-amplitude signals (3), recorded near the ablation site. B: Demonstration of the postpacing interval equal to the tachycardia cycle length of 446 ms at the ablation site. C: Demonstration of no change in flutter wave morphology on the surface electrocardiogram (ECG) during entrainment pacing and spontaneous tachycardia. Only the last paced P wave and the first P wave during tachycardia were shown. ECG labels from top to bottom: I, II, III, aVR, aVL, aVF, V1, V2, V3, V4, V5, V6. D: Termination of the atypical atrial flutter during ablation, followed by dual-chamber paced rhythm with delayed atrial activation (recorded after ventricular electrogram) on the Lasso and ultimate complete electrical isolation of the residual appendage area. Note the near-instantaneous termination of the flutter as the low-amplitude atrial electrograms start to appear on the ablation catheter as it moves toward the concealed entrainment site (arrows). Only far-field ventricular signals were present on the Lasso catheter toward the end of the recording. The Lasso catheter was positioned near the remnant appendage area, between the left superior pulmonary vein and mitral annulus. E: Position of the ablation and Lasso catheters at the time of concealed entrainment and during flutter termination (arrows) on 2 orthogonal views on CARTO. LAO = left anterior oblique; RAO = right anterior oblique. HeartRhythm Case Reports 2017 3, 352-356DOI: (10.1016/j.hrcr.2017.05.004) Copyright © 2017 Heart Rhythm Society Terms and Conditions

Figure 3 Schematic drawing of the successful ablation site in relationship to left atrial anatomy and depiction of AtriClip position based on intraoperative CARTO mapping as well as preoperative transesophageal echocardiogram (TEE) and computed tomographic (CT) imaging. A: A presumed flutter circuit was drawn around the AtriClip. Dotted line indicates areas of slow conduction detected during mapping. Solid arrow indicates area of relatively normal conduction. LAO = left anterior oblique. B: TEE showing the remnant of the left atrial appendage (LAA) and the closure line from the AtriClip device, between the left superior pulmonary vein (LSPV) and the mitral annulus. C: CT image (coronal view) showing the relationship between the LSPV and the AtriClip, similar to the relationship between the Lasso catheter placed in the LSPV and the successful ablation site as demonstrated in panel D. The arrow denotes the AtriClip LAA closure device. D: The arrow shows the successful ablation site leading to flutter termination. The circular Lasso catheter is placed inside the LSPV. AP = anteroposterior. HeartRhythm Case Reports 2017 3, 352-356DOI: (10.1016/j.hrcr.2017.05.004) Copyright © 2017 Heart Rhythm Society Terms and Conditions