Title : Successful isolation of right Accessory pulmonary veins using a variable-loop pulsed-field ablation catheter
Abstract:
Background: Pulmonary vein isolation (PVI) is the cornerstone of catheter ablation for AF and is dependent on achieving durable electrical isolation of all pulmonary veins (PVs). Anatomical variations, such accessory PVs, are common and can lead to incomplete isolation and arrhythmia recurrence. With radiofrequency ablation (RFA), this would involve meticulous point-by-point applications, increasing procedure time and risk for complications. Pulsed-field ablation (PFA) is a novel, non-thermal ablation method that achieves cell death via irreversible electroporation and utilize variable shaped catheters that may be better suited to address variant anatomies. This report describes the successful use of PFA for the isolation of accessory PVs during a standard PVI procedure and highlights the safety and efficiency of PFA systems in managing complex venous anatomy.
Case: A 75-year-old male with HFpEF and symptomatic persistent AF presented for ablation. Pre-procedural CT identified a complex right-sided venous anatomy comprising four separate PVs: principal superior, accessory superior, accessory middle, and principal inferior PVs (Figure 1A). Electroanatomic mapping with the Pentaray mapping catheter in the CARTO 3 system (Biosense Webster, Inc. Irvine, CA, USA) confirmed distinct ostia for the accessory PVs (Figure 1B). PVI was performed using the Varipulse PFA catheter. The variable-loop design facilitated isolation of the accessory PVs by adjusting the catheter diameter to match the specific ostial dimensions. PFA was delivered to the ostia and antra. Post-ablation mapping and pacing confirmed bidirectional block in all PVs (Figure 1C). There were no acute complications. At 1-month follow-up, the patient remained in sinus rhythm and asymptomatic.
Conclusion: This case demonstrates the feasibility, safety, and efficiency of using PFA to treat a patient with complex PV anatomy, which typically requires the creation of a more complex lesion set compared to a standard four-vein anatomy.
