ICE cases content
Zero fluoroscopy technique for atrial fibrillation ablation: Anatomical step by step guide.
Alejandro Jimenez Restrepo 1,2, Jason Appelbaum 2. 1. University of Maryland School of Medicine. Baltimore, MD, USA. 2. Florida Electrophysiology Associates. Atlantis, Florida, USA.
Step guide 3-4
Fast anatomical map (FAM) of the RA. The decapolar catheter is advanced from the IVC up to the SVC, then dragged down into the RA appendage base anteriorly, tricuspid annulus and the His bundle location is annotated. The contours of the right atrium are delineated in order to create a matrix to allow for the Vizigo Sheath to be visible on the 3DEAM throughout the transseptal process. The catheter is finally positioned in the CS or high RA/SVC junction.
Single transseptal access. The Vizigo sheath (visible on the 3DEAM) is advanced over a J shaped guidewire and positioned in the SVC. (Video 3)
Video 3. Left panel. Advancement of Vizigo sheath (Biosense Webster) from the inferior vena cava into the right atrium and superior vena cava in preparation for transseptal access. RAO and LAO projections of the RA fast anatomical map (FAM) with CartoSound based geometry of left atrial structures as seen on figure 1 and video 2. Right panel: Still ICE frame of RA long axis view showing the position of the TS sheath in the SVC/RA junction.
The ICE FOV is directed towards the left veins and slight posterior and rightward tilt allows visualization of the SVC. A J guidewire is advanced into the SVC, allowing for safe advancement of the Vizigo sheath. A TS needle is advanced into the sheath, and the needle/sheath assembly are dragged down in a 2-4 O’clock position (depending on heart rotation) aligning the orientation of the Vizigo sheath with the annotated location for TS access (RAO/LAO or posterior views). The TS sheath is visualized from the SVC into the RA septum and IAS membrane (tenting sign on ICE). Once tenting is confirmed, TS access is obtained in the standard fashion (in our example a radio-frequency needle is used). After saline bubbles are observed in the LA, the TS needle is pulled into the dilator and with direct ICE visualization of the TS sheath dilator tip, carefully advanced into the mid LA cavity. At this point forward pressure is applied to the TS sheath while the dilator is pulled into the TS sheath. Usually the sheath will advance into the LA (Seen on ICE and 3DEAM) (Video 4).
Video 4. Transseptal access. 3DEAM in orthogonal views and ICE FOV on the IAS shows tenting before crossing with the TS needle and saline bubbles seen in the LA. Forward pressure on the TS sheath as the dilator is pulled back allowed for crossing of the sheath.
If the TS sheath does not cross with forward pressure, removing the TS needle and advancing a J guidewire into one of the left pulmonary veins allows for more forward pressure to be applied and the TS sheath to advance over the wire, without risking posterior LA wall laceration (Video 5). Once the TS sheath has crossed the IAS membrane, dilator and TS needle (or guidewire if used) are removed.
Video 5. Transseptal access using a J guidewire for sheath advancement. The TS sheath did not cross with forward pressure. The TS needle was removed and a J guidewire was placed inside the LSPV and the TS sheath and dilator were advanced. During crossing the tenting disappears on ICE and the TS sheath is seen advancing towards the LSPV on 3DEAM. LA sheath placement is confirmed on ICE by readjusting the FOV after crossing.