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.