Left Atrium Calcification After Multiple Catheter Ablation Procedures for Atrial Fibrillation

A 79-year-old woman presented to hospital with recurrent atrial tachycardia (AT) after multiple ablation procedures for atrial fibrillation (1st and 2nd sessions: pulmonary vein isolation; 3rd session: left atrium [LA] posterior wall isolation and additional linear ablation). Echocardiography revealed worsening pulmonary hypertension (PH) after the third session (Supplementary Table). Computed tomography before this session showed calcification of the LA (Figure A,B), which was unremarkable before the 3rd session, performed 9 years ago (Figure C). Calcification was also observed on fluoroscopy (Figure D). The V wave of the LA pressure was elevated (Figure E). Calcified lesions reconstructed using a 3D-mapping system and intracardiac ultrasound (Figure F) accurately demonstrated their distribution (Figure G), consistent with the previous ablation site (Figure H). AT was successfully ablated at the anterior LA wall (non-calcified lesions) without complications.

Figure.

Computed tomography before the 4th (A,B) and 3rd sessions (C). Fluoroscopy showed calcification (D). Elevated V wave (E). Distribution of the calcified lesions on 3D-mapping system (F,G), consistent with the previous ablation site at the 3rd session (H), using an irrigation catheter with a maximum output of 30 W and a maximum temperature of 42℃ (the atrial dwell time was 56 min).

LA calcification (“Coconuts LA”) is a rare condition in rheumatic valve and endstage renal disease. The patient had no such history, and the pathophysiology remains unclear; however, “stiff LA syndrome” of diastolic dysfunction associated with PH is reported as a rare complication after ablation.¹ This case may be a manifestation of stiff LA syndrome. Electrophysiologists should be aware that extensive LA ablation rarely causes diastolic dysfunction.

Disclosures

The authors declare that they have no conflicts of interest.

IRB Information

Ethics Committee Approval no. 21D072.

Supplementary Files

Please find supplementary file(s);

http://dx.doi.org/10.1253/circj.CJ-21-0583

Reference

• 1.   Gibson DN, Di Biase L, Mohanty P, Patel JD, Bai R, Sanchez J, et al. Stiff left atrial syndrome after catheter ablation for atrial fibrillation: Clinical characterization, prevalence, and predictors. Heart Rhythm 2011; 8: 1364–1371.