Europace Advance Access published online on June 18, 2008
Europace, doi:10.1093/europace/eun165
Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2008. For permissions please email: journals.permissions@oxfordjournals.org
CASE REPORT
Successful catheter ablation of atrial fibrillation in a patient with dextrocardia
Takumi Yamada*,
Hugh Thomas McElderry,
Harish Doppalapudi,
Michael Platonov,
Andrew E. Epstein,
Vance J. Plumb and
George Neal Kay
Division of Cardiovascular Disease, University of Alabama at Birmingham, VH B147, 1670 University Boulevard, 1530 3rd Avenue South, Birmingham, AL 35294-0019, USA
Manuscript submitted 4 February 2008. Accepted after revision 26 May 2008.
* Corresponding author. Tel: +1 205 975 4724; fax: +1 205 975 4720. E-mail address: takumi-y{at}fb4.so-net.ne.jp
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Abstract
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A 49-year-old woman with dextrocardia and situs inversus underwent
catheter ablation of paroxysmal atrial fibrillation. A contrast
injection into the left atrium revealed that the left atrial
appendage (LAA) was adjacent to the right-sided (anatomic left)
superior pulmonary vein (PV). After successful isolation of
that PV, LAA potentials were recorded from several electrode
pairs of a circular PV mapping catheter. LAA may cause similar
difficulties during PVI of the right-sided superior PV in a
dextrocardia patient, as during PVI of the left superior PV
in a normal heart.
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Case report
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A 49-year-old woman with dextrocardia and situs inversus without
any underlying disease linked to that disorder was referred
for catheter ablation of drug-refractory paroxysmal atrial fibrillation
(AF). Transoesophageal echocardiography revealed a patent foramen
ovale. At the electrophysiological study, a 6 Fr decapolar catheter
(Polaris X
TM, EP Technologies, Boston Scientific Corporation,
San Jose, CA, USA) was introduced into the coronary sinus via
the femoral vein. A 6 Fr quadripolar catheter (Viking
TM, Bard
Electrophysiology, Lowell, MA, USA) was positioned in the His-bundle
region. Trans-septal catheterization via the patent foramen
ovale was successfully achieved using a 7.5 Fr, 3.5 mm tip-irrigated
ablation catheter (NAVI-STAR
TM T
HERMOC
OOLTM, Biosense Webster,
Diamond Bar, CA, USA) through the 8 Fr trans-septal sheath (SL2
TM,
St Jude Medical, AF Division, Minnetonka, MN, USA) via the femoral
vein with fluoroscopic guidance. A contrast injection into the
left atrium via the trans-septal sheath revealed that the left
atrial appendage (LAA) was located adjacent to the right-sided
superior pulmonary vein (PV) (
Figure 1). After PV angiograms
were obtained (
Figure 1), circumferential PV isolation
(PVI) was performed with the guidance of a 20-electrode circular
mapping catheter (Lasso
TM, Biosense Webster). Successful PVI
was defined as either the abolition or dissociation of the distal
PV potentials and was confirmed using a circular mapping catheter
positioned in the distal PVs. After successful PVI of the left-sided
PVs, incessant AF episodes occurred spontaneously. A circular
mapping catheter positioned within the right-sided superior
PV revealed that the AF originated from that PV (
Figure 2).
After successful isolation of that PV, sinus rhythm was maintained.
However, relatively large potentials were recorded from several
electrode pairs of the circular mapping catheter positioned
at the PV ostium (
Figure 2). Differential pacing from the
distal coronary sinus and LAA was performed and demonstrated
that those potentials reflected the LAA activity (
Figure 2).
Successful isolation of all PVs was achieved without any complications.
No atrial tachyarrhythmias have recurred during 3 months of
follow-up.
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Figure 1 Fluoroscopic images exhibiting the anatomical relationship between the left atrial appendage (left panels) and right-sided (anatomic left) superior pulmonary vein (middle panels), and the circular mapping catheter positioned within that pulmonary vein (right panels). The upper panels exhibit the left anterior oblique view and the lower panels the right anterior oblique view. ABL, the ablation catheter; LAA, left atrial appendage; CS, coronary sinus.
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Figure 2 Cardiac tracings recorded during the onset of atrial fibrillation (left panel) and after successful pulmonary vein isolation (middle and right panels). The arrowheads in the left panel indicate the atrial premature beat triggering the atrial fibrillation and the arrows in the middle panel indicate the left atrial appendage potentials. AF, atrial fibrillation; PVI, pulmonary vein isolation; CSd, the distal coronary sinus; L, circular mapping catheter. The other abbreviations are as in Figure 1.
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To the best of our knowledge, this is the first report illustrating
a successful PVI in a dextrocardia patient. In a normal heart,
the LAA may sometimes cause difficulties during PVI of the left
superior PV because a mapping or ablation catheter may easily
slip into the LAA and the LAA potentials may masquerade as PV
potentials.
1
On the contrary, in PVI in a dextrocardia patient,
it should be kept in mind that the LAA may cause similar difficulties
during PVI of the right-sided superior PV.
Conflict of interest: T.Y. is supported by a research grant from Boston Scientific and St Jude Medical. A.E.E., G.N.K., H.T.M., and V.J.P. have participated in catheter research funded by Biosense-Webster and Irvine Biomedical. G.N.K. has received honoraria from Medtronic, Boston Scientific, and St Jude Medical. A.E.E. has received honoraria from and served on events committees for Boston Scientific and St Jude Medical. The electrophysiology fellowship program at the University of Alabama at Birmingham receives funding support from Boston Scientific and Medtronic.
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Reference
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[1] Shah D, Haissaguerre M, Jais P, Hocini M, Yamane T, Macle L, et al. Left atrial appendage activity masquerading as pulmonary vein potentials. Circulation (2002) 105:2821–5.
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Abstract
Case report