PV ISOLATION IN PATIENT WITH PFO OCCLUDER DEVICE

Abstract Introduction Many patients are treated with percutaneous placement of atrial septal defect closure devices. In these patients the risk of developing atrial fibrillation is also increased. Pulmonary vein isolation (PVI) requires transseptal puncture but the treatment by catheter ablation is underutilized in the presence of the closure device due to the perceived difficulty of obtaining transseptal access. Case report We report the case of 54–year–old men with drug–refractory symptomatic atrial fibrillation and an occluder patent foramen ovale (AMPLATZER Septal Occluder 25mm, Abbott) implanted and who was referred to our center for catheter ablation. A preliminary study with transesophageal echocardiography carried out to detect the presence of left atrial appendage thrombus highlighting anatomical details. The more cranial position of the PFO Occluder in the septum allowed a more caudal approach of transseptal puncture (about 12 mm); the crossing of the septum was possible bypassing the device, so the PVI isolation was programmed (Figure 1). A quadripolar catheter was introduced via right femoral vein into the coronary sinus under fluoroscopic guidance. An ultrasound catheter (AcuNav, Biosense) was placed in the contralateral femoral vein for intracardiac echocardiographic monitoring. This method facilitates the placement of the needle in the precise location against the atrial septum, in this case more caudal than Amplatzer. A transseptal needle (BRK, Abbott) was advanced through a long sheath (Preface, Biosense) against the septum to gain the access of the left atrium (Fig. 2); the presence of the bubbles, the variation in pressure and the contrast that highlights left atrial confirm the access. A 28mm cryoballoon (10.5Fr Arctic Front Advance Pro, Medtronic) was advanced through a steerable sheath (15Fr FlexCath, Medtronic) over the wire up to the left atrium, inflated and positioned in the atrium to aim PVs occlusionv (Fig. 3). Each PV was frozen for 240s and the isolation was achieved and documented in all PVs. No complications occurred and the patient was discharged the following day. Conclusion This case demonstrates that transseptal puncture in pulmonary vein isolation with an inserted PFO occluder under intracardiac echocardiography monitoring is safe and feasible. A preliminary study with transesophageal echocardiography is useful to clarify anatomical details to facilitate transseptal puncture as well as to exclude the presence of thrombosis in the left atrial appendage.