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• W1977843924 abstract "A 59-year-old man underwent minimally invasive thoracoscopic surgical ablation for symptomatic persistent atrial fibrillation (AF) of 7 years’ duration. His medication consisted of propafenon, metoprolol, and warfarin. Normal left ventricular systolic function and an enlarged left atrium with a volume of 86 mL (normal <66 mL) were observed on transthoracic echocardiography. Computed tomography of the coronary arteries revealed no significant stenosis. During this procedure, the pulmonary veins (PVs) were isolated in pairs using a bipolar radiofrequency clamp (Atricure, West Chester, Ohio). A roofline connecting both superior PVs and an inferior line from one inferior PV to the other were made using a bipolar radiofrequency linear pen device (Coolrail, Atricure). Thus, we created a so-called box lesion. Because of the ongoing AF, a left fibrous trigone line was created using a bipolar radiofrequency pen device (Isolator Pen, Atricure). This connecting lesion was placed from the left fibrous trigone at the anterior mitral valve annulus across the anterior dome of the atrium to the roofline. Because the patient remained in AF at the end of the procedure, he underwent electrical cardioversion. After an uneventful postoperative recovery, he was discharged with a prescription for warfarin and his preoperative antiarrhythmic drug regimen. Initially, the patient remained asymptomatic, and the 7-day Holter monitor recordings at 3 and 6 months revealed continuous sinus rhythm. The warfarin and antiarrhythmic drug regimen were stopped. However, 7 months after the procedure, a symptomatic left atrial flutter was documented (Figure 1). Rate control with metoprolol was initiated combined with warfarin. After informed consent, the patient was scheduled for an electrophysiologic study. After transseptal puncture and placement of a His and a coronary sinus catheter, an activation and endocardial voltage map of the tachycardia was made using a three-dimensional electroanatomic mapping system (CARTO, Biosense-Webster, Diamond Bar, Calif; Figure 2). Combined with concealed entrainment mapping, we were able to confirm a counterclockwise left atrial flutter evolving around the mitral valve annulus. By placing a properly sized circular mapping catheter (Lasso, Biosense Webster) at the antrum of the PVs, complete isolation could be proved during tachycardia by the absence of the PV potentials. Also, the box appeared to be isolated, because we detected no nearfield signals on the Lasso catheter placed at the posterior wall of the left atrium. At the endocardial level of the left fibrous trigone line, the voltage map revealed a line of low voltages but no scar extending from the mitral valve annulus toward the medial aspect of the roof line. This indicated that the left fibrous trigone linear lesion created during the surgical ablation procedure was not transmural. Using a 3.5-mm-tip catheter (ThermoCool, Biosense Webster), we ablated all the remnant low voltages along this line, starting at the mitral valve annulus (Figure 2). During ablation, we saw a gradual increase in the tachycardia cycle length, and connection of the endocardial linear lesion with the roofline resulted in conversion to sinus rhythm (Figure 1, B and C). Bilateral video-assisted thoracoscopic PV isolation is a safe, beating-heart approach for curative surgical treatment of AF.1Wolf R.K. Schneeberger E.W. Osterday R. Miller D. Merrill W. Flege J.B. et al.Video-assisted bilateral pulmonary vein isolation and left atrial appendage exclusion for atrial fibrillation.J Thorac Cardiovasc Surg. 2005; 130: 797-802Abstract Full Text Full Text PDF PubMed Scopus (286) Google Scholar Linear lesions are known to improve the outcome of catheter ablation in patients with persistent atrial fibrillation.2Willems S. Klemm H. Rostock T. Brandstrup B. Ventura R. Steven D. et al.Substrate modification combined with pulmonary vein isolation improves outcome of catheter ablation in patients with persistent atrial fibrillation: a prospective randomized comparison.Eur Heart J. 2006; 27: 2871-2878Crossref PubMed Scopus (273) Google Scholar The left fibrous trigone line was introduced by Edgerton and colleagues.3Edgerton J.R. Jackman W.M. Mack M.J. A new epicardial lesion set for minimal access left atrial maze: the Dallas lesion set.Ann Thorac Surg. 2009; 88: 1655-1657Abstract Full Text Full Text PDF PubMed Scopus (75) Google Scholar This linear lesion serves as an alternative to the endocardial mitral isthmus line extending from the left inferior PV to the mitral valve annulus. The creation of a completely transmural left fibrous trigone line can be hampered by the presence of epicardial fat. Not completely transmural lesions exhibit zones of low voltages and conduction slowing and can become pro-arrhythmic.4Sawhney N. Anousheh R. Chen W. Feld G.K. Circumferential pulmonary vein ablation with additional linear ablation results in an increased incidence of left atrial flutter compared with segmental pulmonary vein isolation as an initial approach to ablation of paroxysmal atrial fibrillation.Circ Arrhythm Electrophysiol. 2010; 3: 243-248Crossref Scopus (168) Google Scholar In our patient, an incomplete left fibrous trigone line resulted in left atrial flutter. Most of these iatrogenic arrhythmias are very symptomatic. To prevent, as much as possible, such reentry circuits from occurring, it is of paramount importance to prove complete transmurality of each deployed linear lesion. This can effectively be done using an epicardial approach or a combined simultaneous thoracoscopic surgical and transvenous catheter procedure.5Pison L. La Meir M. Maessen J. Crijns H.J. Hybrid thoracoscopic surgical and transvenous catheter ablation of AF, towards single procedure ablation of longstanding AF.Heart Rhythm. 2010; 7: S398Google Scholar" @default.
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• W1977843924 date "2011-11-01" @default.
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• W1977843924 title "Left atrial flutter due to incomplete left fibrous trigone linear lesion" @default.
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