PMC6342726_01
A: The 12-lead electrocardiogram (ECG) represents a regular usual complex tachycardia obtained in the emergency department. B: The 12-lead ECG in sinus rhythm.
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The patient underwent synchronized cardioversion with restoration of sinus rhythm (Figure 1).
Percutaneous transhepatic venous access. A: Ultrasound-guided visualization of microneedle puncture to reach the middle hepatic vein. B: Access to the right atrium guided by fluoroscopy through a 5F long sheath dilator and the 0.035-inch wire. C: Once hepatic venous access is obtained, a large 8.5F deflectable sheath is advanced over a guidewire into the right atrium. D: After retrieval of the deflectable sheath, there is ultrasound evidence of an intraparenchymal tract (blue arrow). E: A vascular embolization coil is placed at the parenchymal-tract interface just outside of the vessel lumen, successfully closing the hepatic tract (blue arrow).
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A 5F long sheath dilator was then advanced, and the wire was exchanged for a 0.035-inch wire to allow insertion of an 8.5F bidirectional deflectable sheath (Agilis NxT, Abbott; Figure 2).
Atrial tachycardia ablation guided by a 3-dimensional mapping system. A: Intra-atrial reentrant tachycardia (IART) with a tachycardia cycle length of 330 ms and concealed entrainment from the suprahepatic vein-right atrium (RA) isthmus successfully terminated with linear ablation achieving bidirectional block. B: IART with a tachycardia cycle length of 290 ms and concealed entrainment along the posterolateral RA scar successfully terminated with linear ablation and bidirectional block. C: Focal atrial tachycardia with tachycardia cycle length of 600 ms with earliest centrifugal activation just below the coronary sinus os, successfully eliminated with focal ablation lesions.
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After we exchanged the ablation catheter for 2 4F diagnostic catheters advanced through the deflectable sheath and positioned on opposite sides of the ablation line, bidirectional block across the suprahepatic tricuspid isthmus was confirmed (Figure 3A). Atrial capture with concealed entrainment and a postpacing interval between 290 and 320 ms was seen along the posterolateral RA scar (Figure 3B). RA with the double-catheter technique, the activation map of this third tachycardia showed a focal source with the earliest atrial activation near the ostium of the coronary sinus (-44 ms pre-P wave). Radiofrequency applications near the coronary sinus ostium terminated the tachycardia, and sinus rhythm was restored (Figure 3C).