A 76-year-old man with hypertension and congestive heart failure (CHADS2 [Congestive Heart Failure, Hypertension, Age, Diabetes, Stroke/Transient Ischemic Attack] = 3; CHA2DS2-VASc (Congestive Heart Failure, Hypertension, Age [≥75 y], Diabetes, Stroke/Transient Ischemic Attack, Vascular Disease, Age [65-74 y], Sex [Female] = 4) underwent catheter ablation for 7-month persistent atrial fibrillation (AF). Intracardiac echocardiography (ICE) (Soundstar Biosense Webster, Diamond Bar, CA) advanced in the pulmonary artery (PA) through the right atrium (RA) and the right ventricle showed no thrombi in the left atrial appendage (LAA) with a flow velocity of 7-18 cm/s during AF. Both pulmonary veins were isolated circumferentially 12 hours after the last intake of dabigatran. AF was terminated by intracardiac cardioversion, followed by linear ablation at the lateral mitral isthmus to treat the induced atrial tachycardia. At the end of the session, ICE imaging revealed a solid 3 × 4 mm mobile mass in the tip of the LAA (Fig. 1A-C; Video 1 view video online) observed from the PA (Fig. 1D). The activated clotting time was maintained over 300 seconds throughout the procedure by intravenous administration of heparin. Before ablation, examination by cardiac computed tomography detected a remarkable incomplete enhancement in the LAA without thrombi (Fig. 1E). The left atrial size on transthoracic echocardiography was 4.6 cm, and the ostial flow velocity of the LAA measured using transesophageal echocardiography was 30-36 cm/s during AF with evidence of spontaneous echo contrast without thrombi (Fig. 1F). LAA angiography during ablation showed no defect in the LAA.
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- A prospective comparison of cardiac imaging using intracardiac echocardiography with transesophageal echocardiography in patients with atrial fibrillation: the intracardiac echocardiography guided cardioversion helps interventional procedures study.Circ Arrhythm Electrophysiol. 2010; 3: 571-577
Published online: January 21, 2014
Accepted: January 14, 2014
Received: December 4, 2013
See page 465.e5 for disclosure information.
© 2014 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.