2018 Volume 82 Issue 5 Pages 1476-1477
A 78-year-old male patient with a history of highly symptomatic paroxysmal atrial fibrillation underwent pulmonary vein (PV) isolation (PVI) using a radiofrequency hot-balloon (RHB) catheter (SATAKE Hot-Balloon, Toray Industries, Tokyo, Japan).1 After simultaneous PV angiography (Figure 1A) and successful isolation of the right PV, isolation of the left superior PV (LSPV) was attempted. Initially, a soft J-tipped guidewire (Spring Guide Wire, Toray Industries, Tokyo, Japan) was advanced into the upper branch of the LSPV (Figure 1B) and energy was applied for 240 s at 70℃. Residual conduction of the LSPV was found at the anterior carina, and further energy application at the left inferior PV (LIPV) isolated the LSPV (“cross-talk” phenomenon; Figure 1C). Re-conduction of the LSPV was observed after the termination of energy delivery. Therefore, we advanced the guidewire into the first branch of the LSPV, directing it in the anterior-inferior direction to achieve better contact of the RHB against the LSPV anterior carina. During the first attempt, the guidewire was advanced without complications beyond the cardiac silhouette under fluoroscopy guidance and was assumed to be in the target branch. Selective angiography from the tip of the RHB demonstrated leakage of contrast media into the pericardial space, and the appearance of pectinate muscles suggested that the tip of the RHB perforated the floor of the left atrial appendage (LAA; Figure 2). The guidewire was left in the pericardial space and a touch-up ablation using an irrigated radiofrequency ablation catheter eliminated the residual conduction at the anterior LSPV carina. After administration of anti-coagulant, the guidewire was withdrawn to the LA and a loss of motion of the left heart border on fluoroscopy was detected immediately. Pericardiocentesis was performed and the aspiration of blood (650 mL) stabilized the hemodynamic condition. The patient was discharged 4 days after the procedure without any sequela.
(A) Simultaneous pulmonary vein (PV) angiogram, with the branch of the left superior PV (LSPV) in the anterior-inferior direction (white arrowheads). (B) Position of the guidewire and radiofrequency hot-balloon (RHB) during the initial energy application for the LSPV. (C) Position of the guidewire and RHB during the isolation of the left inferior PV (LIPV). (D) Disappearance of the LSPV potential during the LIPV isolation (“cross-talk” phenomenon). AP, anterior-posterior; CS, coronary sinus; dis, distal; LAO, left anterior oblique; prox, proximal.
(A) Position of the guidewire and RHB during the second energy application. Black arrowheads, leakage of the contrast media into the pericardial space. (B) Reconstructed anatomy of the left atrium and PV. Of note, the branch of the LSPV (red arrows) was parallel to the left atrial appendage (LAA). Abbreviations as in Figure 1.
The RHB consists of a compliant balloon that can achieve better contact with irregularly shaped PV ostia and is used with the soft J-tipped guidewire. The stiff proximal part of the wire enables maintenance of the coaxial position of the balloon, while the floppy distal part (6 cm from the tip of the guidewire) prevents unnecessary trauma. This is the first reported case of LAA perforation caused by the soft J-tipped guidewire during PVI using the RHB. Several case reports have described cardiac perforation using the soft J-tipped guidewire during central venous catheter insertion,2,3 which was performed without fluoroscopy. In the present case, the LSPV branch, which was oriented in the anterior–inferior direction and ran parallel to the LAA body, was targeted to obtain better contact against the anterior carina, and the guidewire was advanced uneventfully beyond the cardiac silhouette under fluoroscopy. Until the selective angiography was performed, we believed that the guidewire was inserted in the LSPV branch, and not in the LAA.
The force required to perforate the atrial wall has been reported to be correlated with catheter size.4 In the present case, the guidewire perforated the floor of the LAA after the guidewire had turned around at the LAA roof. Although the force of the guidewire tip was assumed to be relatively small after it turned around at the roof, the guidewire tip migrated between the pectinate muscles, where the wall was paper thin,5 and may have easily perforated the LAA floor. Moreover, the stiff proximal part of the guidewire may have increased the force of the soft-J tipped guidewire. As already used with the cryoballoon, the circular mapping catheter prevents migration between the pectinate muscles, while the recoding of a local signal helps the operator recognize the inadvertent deployment of the catheter into the LAA. The development of an inner circular mapping catheter or a guidewire with the capability of recording a local signal designed specifically for the RHB may help to maintain the coaxial position and reduce the risk of trauma during manipulation.
K.A. belongs to the endowed department of Toray Industries. The other authors declare no conflict of interest.
