A superior right jugular approach to perform pulmonary vein isolation using Farapulse pulsed-field ablation

Excerpt

A 54-year-old woman was referred to our clinic for pulmonary vein isolation (PVI) because of drug-refractory symptomatic paroxysmal atrial fibrillation. Echocardiography demonstrated a normal left ventricular function and an enlarged left atrium (left atrial volume index 48 ml/m2). She had a history of deep venous thrombosis of the right leg. Initially, an attempt was made to perform ablation through the right femoral vein. Although we obtained femoral vein access, we could not advance the catheters. Bilateral venography revealed occlusion of both iliac veins with extensive formation of collateral veins. We aborted the procedure and rescheduled the patient for PVI under general anesthesia. During this second procedure, we obtained the right jugular vein access guided by vascular ultrasound. A quadripolar catheter was placed in the coronary sinus. Next, we performed a transesophageal echocardiography-guided transseptal puncture using a Swartz braided LAMP 45 transseptal sheath (Abbott, IL, USA) with a BRK-1 needle (Abbott, IL, USA) after giving extra curvature. Because the superior vena cava is closer to the septum than the inferior vena cava, it was relatively difficult to create enough pressure on the septum with the right angulation. Adding a stronger curvature to the distal needle helped overcome this. The transseptal sheath was exchanged for a Farapulse Faradrive steerable sheath (Boston Scientific, MA, USA), with which the Farawave catheter (Boston Scientific, MA, USA) could reach all four pulmonary vein ostias. All pulmonary veins were ablated successfully with pulsed-field ablation following a standard protocol (per vein: two applications in basket configuration, 36° rotation, two applications in basket configuration, two applications in flower configuration, 36° rotation, and two applications in flower configuration). Figure 1 shows the catheter in basket configuration, engaging each vein. During the procedure, the activated clotting time was 349 s, left atrial dwelling time was 39 min, fluoroscopy time was 40 min, and the total procedure time was 105 min. After removing the catheters, the heparin was neutralized with protamine. The puncture site was closed with a Z-stitch and manual compression. The patient was discharged the next day in good condition.

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