Case Report
A 62-year-old female patient with paroxysmal atrial fibrillation,
CHADS-VASc score 3, symptomatic despite treatment with propafenone,
was referred for elective percutaneous ablation.
The procedure was performed under general anesthesia, after left
appendage thrombus being discarded by transesophageal echocardiography.
Triple femoral venipuncture was performed, flushed with 5,000 units of
heparin. We positioned a standard deflective decapolar catheter across
the coronary sinus. Transseptal puncture was performed in a conventional
manner, guided by fluoroscopy, using right and left anterior oblique
views. After first puncture, the sheath was advanced over the needle but
no blood content was observed by lumen aspiration. We opted to advance a
long guidewire to confirm that the sheath was inside the pericardial
space (Figure 1). Due to maintained hemodynamic stability and absence of
cardiac tamponade signs, we decided to insert a JR 6F angiography
catheter in the pericardial space (Figure 2). Approximately 30 ml of
citrine pericardial fluid was aspirated. At that moment, the hemodynamic
condition remained stable and therefore we opted to resume the
procedure. Another transseptal puncture was performed without
complications while maintaining negative pressure through the JR
catheter. Activated clotting time (ACT) levels were monitored and
maintained above 300 seconds. Electroanatomical mapping (CARTO 3 –
Biosense Webster Inc., Diamond. Bar, CA, USA) and circumferential
isolation of the 4 pulmonary veins were performed (Figure 3). The
isolation time was approximately 70 minutes.
After that, we proceeded with reversal of heparin levels
with protamine, followed by withdrawal of both sheaths. The JR
angiographic catheter was initially positioned in different points of
the cardiac silhouette as aspiration continued to maintain the negative
pressure (total time of aspiration of 20 minutes). Transthoracic
echocardiogram inside the EP laboratory discarded pericardial
effusion. Anticoagulation was resumed in the day after and the patient
was discharged after 24 hours of observation. No late-onset
complications or arrhythmia recurrence were noted during six months of
clinical follow-up.