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Europace Advance Access originally published online on July 17, 2007
Europace 2007 9(8):643-644; doi:10.1093/europace/eum137
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© The European Society of Cardiology 2007. All rights reserved. For Permissions, please e-mail: journals.permissions@oxfordjournals.org

ATRIAL FIBRILLATION

Unusual insertion and course of left appendage: how imaging can guide atrial fibrillation ablation

Assunta Iuliano1, Giuseppe Stabile1,2,* and Antonio De Simone2

1 Laboratorio di Elettrofisiologia, Clinica Mediterranea, Via Orazio, Napoli 80131, Italy; 2 Laboratorio di Elettrofisiologia, Casa di Cura San Michele, Maddaloni (CE), Italy

Manuscript submitted 2 May 2007. Revision received 21 June 2007. * Corresponding author: Via Diaz 32, 84100 Salerno, Italia. Tel: +39 348 8960534; fax: +39 089 250810. E-mail address: gmrstabile{at}tin.it

Key Words: Atrial fibrillation, Anatomy, Ablation

A 53-year-old man with early-stage, idiopathic dilated cardiomyopathy and 7 years’ history of persistent atrial fibrillation (AF) refractory to drug therapy (amiodarone, sotalol, propafenone) was referred for AF ablation. The patient had effort dyspnoea; an echocardiogram showed left atrial (antero-posterior diameter 46 mm) and left ventricular (end-diastolic diameter 59 mm) enlargement, with reduced left ventricular ejection fraction (43%). The before-procedure data set of computer tomography scan (Somatom Sensation 10, Siemens, Germany) was imported into an electroanatomical system and segmented by means of the dedicated CartoMergeTM software (Biosense-Webster Inc., Diamond Bar, CA, USA) to obtain three-dimensional anatomy of the left atrium and pulmonary veins. As shown in Figure 1A, left appendage had an abnormal origin, below left inferior pulmonary vein, and of course, anterior to both superior and inferior pulmonary vein. The CartoMerge endocardial three-dimensional reconstruction (Figure 1B) of both left appendage and pulmonary veins guided us to deliver radiofrequency pulses around pulmonary vein antrum without entering left appendage (Figure 1C). This finding represents an unusual variant of left atrial appendage anatomy, and, if not recognized before the procedure, ablation could have been prolonged and possibly compromised in safety and efficacy by fruitless attempts to identify left pulmonary vein from left appendage. The wide variety of left atrium anomalies justify any effort to obtain left atrial anatomy details before planning an AF ablation; moreover, the use of image integration allows a precise localization of radiofrequency targets.


Figure 1
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  		Figure 1 Computed tomography image of left atrium (panel A) with the CartoMerge endocardial 3D reconstruction (panel B). In panel C radiofrequency application (red tags) are shown on endocardial reconstruction.

 
Conflict of interest: none declared.


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This Article
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