Epicardial ablation of recurrent left atrial macroreentrant tachycardia from Bachmann's bundle region after endocardial ablation

Background: Pulmonary vein stenosis is a dreaded complication of endocardial atrial fibrillation (AF) ablation but rare after epicardial ablation and has not been reported after epicardial left atrial appendage occlusion (LAAO). Case: A 55-year-old male was referred to our tertiary hospital for management of left superior pulmonary vein (LSPV) stenosis causing dyspnea on exertion. About 2 years prior to presentation, he underwent quadruple coronary artery bypass grafting for non-ST elevation myocardial infarction along with modified Cox-Maze procedure with pulmonary vein and posterior wall isolation as well as epicardial LAAO with AtriClip for history of paroxysmal AF. At our institute, V/Q scan showed ventilation-perfusion mismatch and absent perfusion of the left upper lobe (Figure 1A). Cardiac CT showed persistent LSPV occlusion (Figure 1B). TEE showed atrial appendage occluded with a clip and no flow was observed from LSPV (Figure 1C). After multidisciplinary discussion between cardiology and cardiothoracic surgery teams, surgical approach to remove the AtriClip was deemed futile as it was placed 2 years ago and less likely to result in resolution of stenosis. Thus, an endovascular approach was attempted with left atrial and pulmonary vein angiography showing LSPV to be 100% occluded (Figure 1D). Pulmonary vein recanalization was attempted but was not successful. Conclusion: Our case highlights the importance of recognition of PVS as a possible complication after epicardial LAAO as early intervention can improve patient outcomes. PVS has been previously described with Maze procedure but that patient was successfully treated with catheter-balloon angioplasty. Given 100% occlusion and difficulty with recanalization makes epicardial ablation a less likely cause of occlusion in our case. More careful application of Atriclip protocols might be necessary to prevent this potential complication.

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Video-Assisted Epicardial Ablation and Left Atrial Appendage Exclusion for Atrial Fibrillation: Extended Follow-Up

The Annals of Thoracic Surgery ◽

10.1016/j.athoracsur.2007.08.014 ◽

2008 ◽

Vol 85 (1) ◽

pp. 34-38 ◽

Cited By ~ 42

Author(s):

James H. Wudel ◽

Pradipta Chaudhuri ◽

Jeffery J. Hiller

Keyword(s):

Atrial Fibrillation ◽

Left Atrial ◽

Left Atrial Appendage ◽

Atrial Appendage ◽

Epicardial Ablation ◽

Video Assisted

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Predictors of Sinus Rhythm 1 Year after Posterior Left Atrial Surgical Epicardial Ablation

Journal of the American College of Surgeons ◽

10.1016/j.jamcollsurg.2020.08.228 ◽

2020 ◽

Vol 231 (4) ◽

pp. e90-e91

Author(s):

Helen Mari Louise MerrittGenore ◽

Mitchel Milanuk ◽

Harrison Lang ◽

Shane Tsai

Keyword(s):

Sinus Rhythm ◽

Left Atrial ◽

Epicardial Ablation

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Results of the Thoracoscopic Radiofrequency Epicardial Ablation with a Bipolar Electrode During Longstanding Persistent form of Atrial Fibrillation

E3S Web of Conferences ◽

10.1051/e3sconf/202015908007 ◽

2020 ◽

Vol 159 ◽

pp. 08007

Author(s):

Rustem Tuleutaev ◽

Alibek Oshakbayev ◽

Kuat Abzaliyev ◽

Baurzhan Rakishev ◽

Symbat Abzaliyeva

Keyword(s):

Atrial Fibrillation ◽

Left Atrial ◽

Left Atrial Appendage ◽

Bipolar Electrode ◽

Epicardial Ablation ◽

Input And Output ◽

Mean Size ◽

The Mean ◽

Β Blockers

Thoracoscopic ablation using the ‘box lesion’ technique was performed using a bipolar radio frequency clamp. A total of 48 patients, including 38 men and 10 women, mean age 58 years (range 33 74). The mean duration of AF was 4 yrs (range 1.5 months 21), the mean size of the atrium 4.15 ± 0.9 cm (2.9-8.8 cm), mean LVEF was 57.7% (39 -73%). Mitral regurgitation of 1-2 degrees was present in 14 patients, EDV LV 147.7 ml (81-224). Primary catheter ablation was performed in 22 patients, where 5 of them (22,7%) were performed repeatedly. Resection of the left atrial appendage (LAA) during the operation was performed in 44 patients (91%). Input and output block was achieved in all patients. In the postoperative period, all patients were administered supporting antiarrhythmic therapy with amiodarone and β-blockers, anticoagulant therapy with warfarin or PLA for 6-12 months. The effectiveness of treatment was monitored by a cardiomonitor Reveal XT in the period 1, 3, 6, 12, 24 months after surgery, the mean follow-up length was 498 ± 19 days. Sinus rhythm was restored during surgery in all patients and remained until discharge.

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