First-in-human case of repeat pulmonary vein isolation by targeting visual interlesion gaps using the direct endoscopic ablation catheter after single.

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First-in-human case of repeat pulmonary vein isolation by targeting visual interlesion gaps using the direct endoscopic ablation catheter after single ring pulmonary vein isolation William W.B. Chik, MBBS, FRACP, David Robinson, MS, David L. Ross, MBBS, FRACP, FHRS, Stuart P. Thomas, MBBS, FRACP, PhD, Pramesh Kovoor, MBBS, FRACP, PhD, Aravinda Thiagalingam, MBChB, FRACP, PhD HeartRhythm Case Reports Volume 1, Issue 5, Pages 279-284 (September 2015) DOI: 10.1016/j.hrcr.2014.12.009 Copyright © 2015 Heart Rhythm Society Terms and Conditions

Figure 1 Field of view (FOV) through the direct endocardial visualization catheter measuring 2.8 mm across the central hood aperture and 6.8-mm-diameter hood face. The FOV facilitates visual mapping for the anatomic gap of electrical reconnection embedded in the region of earliest activation. Local endocardial tissue electrogram (EGM) signals were recorded by 4 metal-plate contact electrodes situated on the hood face. The electrodes were configured by an EP recording system (Prucka) to provide 4 pairs of contact bipolar EGMs across the hood face and displayed on the EP recording system (Prucka). A Lasso electrode is seen in contact with the left superior pulmonary vein tissue in the FOV. HeartRhythm Case Reports 2015 1, 279-284DOI: (10.1016/j.hrcr.2014.12.009) Copyright © 2015 Heart Rhythm Society Terms and Conditions

Figure 2 A: Electrogram (EGM) captured by direct endocardial visualization DEV hood-face electrodes at the anterior left superior pulmonary vein (LSPV)/left atrial appendage (LAA) ridge. Pulmonary vein potentials were recorded over pink viable endocardium at the site of the interlesion gap (between regions of partially blanched tissue). B: Chronically ablated scar during visual mapping adjacent to the ridge. The electrode bipolar EGM shows attenuated amplitude signals corresponding to fully blanched whitish endocardial tissue as seen through the field of view (FOV). CS = coronary sinus. HeartRhythm Case Reports 2015 1, 279-284DOI: (10.1016/j.hrcr.2014.12.009) Copyright © 2015 Heart Rhythm Society Terms and Conditions

Figure 3 A: Electrograms (EGMs) consistent with electrical reisolation of the left-sided pulmonary veins after successful abolition of visual interlesion gaps at the left superior pulmonary vein (LSPV) ridge. The region was ablated using the virtual electrode of the direct endocardial visualization (DEV) catheter, and the previously pink appearance of the gap is replaced by blanched whitish color ablated myocardium seen on the field of view (FOV) after successful pulmonary vein reisolation. B: Endocardial trabeculae appearance of the left atrial appendage (LAA) as seen through the FOV. Differential pacing was performed using the virtual electrode while the DEV catheter was positioned in the LAA. Upon pacing through the saline bridge of the virtual electrode, the far-field signals on the Lasso were seen to be pulled in from the LAA. HeartRhythm Case Reports 2015 1, 279-284DOI: (10.1016/j.hrcr.2014.12.009) Copyright © 2015 Heart Rhythm Society Terms and Conditions