Entrapment of an ablation catheter in the cardiac venous system: a case report

Influence of PFO Anatomy on Successful Transcatheter Closure

Patent foramen ovale (PFO) is considered a risk factor for serious clinical syndromes, the most important of which is cryptogenic stroke in the setting of paradoxic embolism. The safety and feasibility of transcatheter PFO closure have been addressed in several studies; this procedure is performed worldwide with excellent results. Variations in the atrial septal configuration and PFO are frequent and have an impact on the technical aspects and success in transcatheter PFO closure. To minimize the rate of complications of percutaneous closure of PFO, patients must be carefully selected on the basis of morphology and location of the interatrial defect.

Anatomic Proximity of the Esophagus to the Coronary Sinus: Implication for Catheter Ablation Within the Coronary Sinus

INTRODUCTION

The anatomic proximity between the esophagus and the coronary sinus (CS) might render the esophagus vulnerable to thermal injury during ablation. Therefore, we investigated the anatomic relationship between the esophagus and the CS in patients with atrial fibrillation (AF).

METHODS AND RESULTS

Thirty patients (25 males, mean age = 54 +/- 11 years) with drug-refractory paroxysmal AF were included. Sixteen-slice multidetector computed tomography was performed to depict the course of the esophagus and relationship to the CS. The esophagus was in direct contact with the CS in 57% (17/30) of patients (group 1). The mean length of the contact was 6.1 +/- 3.4 mm. In the remaining 13 patients, the esophagus did not come in direct contact with the CS (group 2). The shortest distance between the esophagus and the CS was 4.0 +/- 2.6 mm. The CS diameter (9.4 +/- 1.8 vs 8.5 +/- 2.4 mm, P = 0.15), esophagus width (18.6 +/- 1.6 vs 18.6 +/- 1.7 mm, P = 0.87), anteroposterior diameter of the left atrium (35.9 +/- 3.8 vs 35.0 +/- 3.3 mm, P = 0.58), thickness of the anterior wall of the esophagus (2.9 +/- 0.6 vs 2.9 +/- 0.6 mm, P = 0.97), and shortest distance from the esophagus to the CS ostium (19.3 +/- 5.4 vs 25.0 +/- 6.2 mm, P = 0.02) and to the great cardiac vein (8.5 +/- 5.3 vs 12.1 +/- 6.9 mm, P = 0.10) were compared between the two groups.

CONCLUSIONS

In 57% of our patients, the esophagus was in direct contact with the CS, and a significantly shorter distance between the esophagus and the CS ostium was noted in these patients. It is important to prevent esophageal damage when applying energy within the CS.

The “pull–push” technique to deal with a redundant eustachian valve interfering with placement of a PFO occluder

OBJECTIVES

To evaluate the role of a new technique to deal with a redundant Eustachian valve (EV) interfering with placement of a patent foramen ovale (PFO) occluder.

BACKGROUND

The EV is a remnant of the embryonic valve of the sinus venosus. In rare occasions, it is large and redundant and it may interfere with catheters and devices used in cardiac catheterization.

METHODS

We have developed a new technique to control the EV in order to avoid interferences with the device for closure of atrial septal defects and PFO's. This technique is called "pull-push" technique and consists in pulling down on the inferior vena cava the redundant EV by using a 6 Fr pigtail catheter while a second operator pushes the right atrial disc out of the long sheath.

RESULTS

Here, we report on two patients with a patent foramen ovale, in whom the EV prevented the right atrial disc of an Amplatzer PFO occluder to be completely flat against the interatrial septum. Finally, we used this technique in one more patient to avoid any interference of a very redundant EV during placement of a Starflex device.

CONCLUSIONS

In conclusion. the so called "pull-push" technique is an alternative and easy technique to control the EV in order to avoid interferences with the device for closure of atrial septal defects and PFO's

Persistent redundant Eustachian valve interfering with Amplatzer PFO occluder placement: anatomico-clinical and technical implications

A 28-year-old man with patent foramen ovale and a prominent Eustachian valve with a history of transient ischemic attack underwent transcatheter closure using Amplatzer patent foramen ovale occluder. During deployment, some of the prominent valve tissue was entrapped on the delivery cable and a piece of the valve was extracted unintentionally. Anatomico-clinical and technical implications are discussed.

Radiofrequency catheter ablation of left-sided accessory pathways in pediatric patients

In many cases, radiofrequency catheter ablation has replaced the long-term use of antiarrhythmic medication for symptomatic tachycardia, and has all but eliminated arrhythmia surgery. The most common substrate for radiofrequency catheter ablation in pediatric patients is atrioventricular (AV) reentry tachycardia due to a concealed or manifest accessory pathway. Accessory pathways are distributed unevenly along the right and left atrioventricular valve annuli, and left-sided accessory pathways are most common. Although some centers advocate an abbreviated diagnostic and mapping approach to both concealed and manifest left-sided accessory pathways, most still use a complete electrophysiological evaluation and complex catheter manipulation for mapping, followed by the application of radiofrequency energy. Left-sided accessory pathways may be approached from the transatrial approach, the retrograde aortic approach, or less commonly from within the coronary sinus. Each approach has proven to be associated with success, but also with a distinct set of risks. Possibly because left-sided accessory pathways are most common, catheter ablation of this substrate has proven highly successful and has the lowest risk of recurrence. However, recent data also suggest that this substrate is associated with greater risk of complications than of right-sided accessory pathways or pathways located in the posteroseptal region. The following report reviews some of the recently described diagnostic and mapping techniques, success rates, risks and follow-up data in pediatric patients undergoing radiofrequency catheter ablation of left-sided accessory pathways.

Entrapment of a guide wire by the Chiari network in a patient with ablated idiopathic ventricular tachycardia

Using a guide wire before insertion of a sheath is a common procedure with infrequent complications. We report an unusual case of a guide wire having been entrapped by the Chiari network prior to an intended radiofrequency ablation procedure, and which could be observed using intracardiac echocardiography. Using transthoracic echocardiography prior to ablation, this patient had been shown to have a relatively large Chiari network. We caution against using a long guide wire in patients with a large Chiari network.