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Catheter ablation of atrial fibrillation and left atrial flutter in a patient with a left atrial appendage occlusion device David A. Steckman, Duy Thai Nguyen, and William H. Sauer* Section of Cardiac Electrophysiology, University of Colorado, 12401 East 17th Avenue, B136, Aurora, CO 80045, USA

* Corresponding author. Tel: +1 720 848 6510; fax: +1 720 848 0475, Email: [email protected]

A 60-year-old woman with atrial fibrillation (AF) and prior implantation of an Amplatzer Cardiac Plug (ACP) left atrial appendage (LAA) occlusion device was referred for ablation. A pre-procedural transoesophageal echocardiography revealed device deformation of the anterior aspect of the left superior pulmonary vein (LSPV) and ligament of Marshall. Delivery of radiofrequency energy near the ACP device resulted in automatic generator shut-off with impedance measurement errors. Sustained mitral annular flutter (MA AFL) was consistently induced with burst pacing. As demonstrated in the figure, electrical isolation of the left PVs and LAA together was achieved with the creation of contiguous ablation lesions connecting the anterior MA to the right superior PV and the lateral MA to the left inferior PV in addition to a posterior lesion set around the left PVs. Ablation in the coronary sinus was required to achieve block. Entrance and exit block was confirmed for all PVs and MA AFL was non-inducible. She has since remained AF free 1 year postprocedure. Our case required a unique ablation set to achieve durable PV isolation. This successfully terminated MA AFL and resulted in LSPV isolation. This ablation approach may be necessary when dealing with patients having LAA occlusion devices, specifically the ACP.

Roof Line Roof Line LSPV

LSPV

LAA Occlusion Device LIPV

Anterior Mitral Line

Inferior Mitral Line

The full-length version of this report can be viewed at: http://www.escardio.org/communities/EHRA/publications/ep-case-reports/ Documents/Catheter-ablation-of-atrial-fibrillation.pdf.

Published on behalf of the European Society of Cardiology. All rights reserved. & The Author 2014. For permissions please email: [email protected]

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doi:10.1093/europace/euu039 Online publish-ahead-of-print 2 March 2014

EP CASE EXPRESS

Catheter ablation of atrial fibrillation and left atrial flutter in a patient with a left atrial appendage occlusion device.

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