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Cardiovascular Images

Real-Time 3-Dimensional Transesophageal Echocardiography During Left Atrial Radiofrequency Catheter Ablation for Atrial Fibrillation

G. Burkhard Mackensen, MD, PhD; Donald Hegland, MD; Danny Rivera, RCS; David B. Adams, RCS, RDCS and Tristram D. Bahnson, MD

From the Division of Cardiothoracic Anesthesia and Critical Care Medicine, Department of Anesthesiology (G.B.M.), and the Division of Cardiology, Department of Medicine (D.H., D.R., D.B.A., T.D.B.), Duke University Medical Center, Durham, NC.

Correspondence to Tristram D. Bahnson, MD, Division of Cardiovascular Medicine, Duke University Medical Center, Box 2959, Durham, NC 27710. E-mail tristram.bahnson@duke.edu

An extract of the first 250 words of the full text is provided, because this article has no abstract.

Left atrial radiofrequency catheter ablation has been recognized as an important treatment option for drug-refractory symptomatic atrial fibrillation.¹ Recent consensus on technique favors catheter ablation directed to the left atrium near the pulmonary vein (PV) ostium to achieve PV isolation.² However, ablation in the region of the ligament of Marshall (LOM) to achieve electrical isolation of the left PVs can be difficult because of variable catheter stability. The superior extent of the LOM protrudes into the body of the left atrium between the anterior region of the left PV antrum and the left atrial appendage (Figure 1A). Inadvertent misdirection of ablative lesions anterior to the LOM in the region of the left atrial appendage increases the risk of cardiac perforation and does not contribute to successful PV isolation, and misdirection of ablative lesions posteriorly into the left PV or posterior left PV antrum can result in PV stenosis or fatal esophageal injury,² respectively. Thus, circumferential isolation of the left PVs via precise delivery of ablative lesions outside the PV ostium, including the region of the LOM ridge, would be expected to enhance procedural safety and efficacy.³ More specifically, enhanced imaging technologies like 3-dimensional (3D) echocardiography, if able to image the ablation catheter and endocardium in real time, would be expected to minimize procedural complications such as PV stenosis, esophageal injury, and cardiac perforation. Although these complications are rare, occurring at rates <1% when contemporary techniques are used,¹ they can be serious or fatal.

View larger version (12K):   Figure 1. A, Two-dimensional TEE. . . . [Full Text of this Article]