Circulation Journal
Online ISSN : 1347-4820
Print ISSN : 1346-9843
ISSN-L : 1346-9843
Images in Cardiovascular Medicine
Silent Cardiac Perforation During Visually Guided Laser Balloon Ablation
Chihiro OtaHiro YamasakiAkihiko NogamiMasaki Ieda
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Supplementary material

2022 Volume 86 Issue 10 Pages 1587-

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A 36-year-old man with atrial fibrillation underwent visually guided laser balloon (VGLB) ablation (CardioFocus Inc, Marlborough, MA, USA). After circumferential energy application, isolation of the left superior pulmonary vein (LSPV) was achieved at the anterior carina (12 W, 67 s) but was transient. Subsequent energy application (12 W, 20 s) on the contralateral side of the left inferior pulmonary vein (LIPV) successfully isolated the LSPV (“cross-talk” phenomenon); however, a gradually expanding black spot was noted behind the balloon at the anterior ridge (Figure A, yellow arrows). On fluoroscopy, extravasation of the contrast media into the pericardial space was observed (Figure B, black arrows, Supplementary Movie). Pinhole rupture of the balloon with extravasation of the inner contrast media directly into the pericardial space was suspected. The patient remained hemodynamically and neurologically stable after balloon deflation. A magnified view of the VGLB demonstrated that the pinholes coincided with the LIPV anterior carina energy application sites (Figure C, red arrows).

Figure.

(A) Endoscopic views during energy applications. (B) Extravasation of the inner contrast media into the pericardial space. (C) A magnified view of the visually guided laser balloon with pinholes (red arrows). LIPV, left inferior pulmonary vein; LSPV, left superior pulmonary vein; VGLB, visually guided laser balloon.

Pinholes typically result in leakage of contrast media into the left atrium rather than into the pericardial space. Although the precise mechanism of the extravasation is unknown, repeated high-energy applications at the LSPV anterior carina may have increased myocardial vulnerability,1 and subsequent energy application on the contralateral side resulted in development of the pinholes and further myocardial damage. Consequently, contrast media leakage occurred via the stretched, vulnerable myocardium without apparent cardiac perforation on endoscopy. Considering that it is not possible to monitor lesion size with VGLB ablation, it should be emphasized that repeated high-energy applications in confined areas may increase the risk of cardiac perforations.

Disclosures

A.N. received honoraria from Abbott and Biosense Webster; and an endowment from Medtronic and DVx. M.I. received honoraria from Fukuda Denshi, Lifeline, and ASTEC Co., Ltd.

Supplementary Files

Supplementary Movie. Extravasation of the inner contrast media directly into the pericardial space.

Please find supplementary file(s);

http://dx.doi.org/10.1253/circj.CJ-22-0012

Reference
 
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