Epicardial ablation of atrial flutter in a patient with esophageal achalasia: a case reportAbstract56-year-old male with persistent atypical atrial flutter (AFL) and a history of surgically treated esophageal achalasia, which contraindicated the use of transesophageal echocardiography (TEE). A contrast-enhanced CT was used to exclude thrombus in the left atrial appendage (LAA). Despite unsuccessful endocardial ablation, epicardial access via the coronary sinus was achieved, resulting in arrhythmia termination after radiofrequency (RF) applications. This case highlights the feasibility of epicardial ablation in atypical AFL and suggests CT as an alternative to TEE for thrombus exclusion in high-risk patients, expanding indications for epicardial procedures in complex AFL cases.Marcin Wita MD, PhD 1, Andrzej Hoffmann MD, PhD1, Magdalena Dobrolińska MD, PhD2,3, Mateusz Polak MD, PhD 1 , Bartłomiej Stasiów MD, PhD 2, Anna Pyszna-Wita PhD2, Dankowski Jakub, Michal Wita PhD, Maciej T. Wybraniec MD, PhD, Professor 1,, Katarzyna Mizia – Stec MD, PhD, Professor 1,1 First Department of Cardiology, School of Medicine In Katowice, Medical University of Silesia, Katowice, Poland, Upper-Silesian Medical Centre, Katowice, Poland,2 Department of Radiology, Upper-Silesian Medical Center, Katowice, Poland,3 Department od Cardiology and Structural Heart Diseases, Medical University of Silesia in Katowice, Poland,Correspondence: Marcin Wita, First Department of Cardiology, School of Medicine In Katowice, Medical University of Silesia, Katowice, Poland, Upper-Silesian Medical Centre, Katowice, Poland, witamarcin9@gmail.comConflict of interest: none declaredThe patient gives permission for the publication of this case history, figures and other clinical informations.KEY CLINICAL MESSAGE:Ablation of atypical flutter is feasible and safe via the coronary sinus, while computed tomography may serve as diagnostic modality to exclude thrombus in left atrial appendage prior to ablation in case of contraindications to transesophageal echocardiographyINTRODUCTIONAblation of atypical atrial flutter represents a challenging electrophysiology procedure, which should be preceded by the exclusion of thrombus in the left atrial appendage (LAA) by means of transesophageal echocardiography (TEE) or computed tomography (CT). Esophageal achalasia is a rare disease, which constitutes a contraindication to TEE on account of decreased esophageal lumen and, hence, increased risk of perforation or bleeding.CASE HISTORYA 56-year-old male with persistent atypical atrial flutter was referred to cardiology department for catheter ablation due to significant symptomatology (EHRA III). The past medical history involved pulmonary vein isolation for atrial fibrillation - 3 months before index hospitalization and surgically-treated esophageal achalasia [1].On admission, transthoracic echocardiography showed enlarged left atrium(LA) of 48mm and reduced left ventricular systolic function of 40%. In ECG was registered atypical atrial fluter 130/min (Figure 1). Given the history of three unsuccessful electrical cardioversions, catheter ablation was considered as the most viable treatment option. Due to the history of esophageal surgery TEE was contraindicated. Consequently, the patient was referred for contrast-enhanced CT in order to exclude the presence of LAA thrombus by means of a three-phase protocol (Figure 2).After confirming the left atrial origin in entrainment study, TactiCath catheter and Advisor mapping electrode were introduced into LA via a transseptal approach. Detailed electroanatomical mapping was performed using EnSite X system, which enabled to visualize low voltage zone within the entire LA. The mapping data allowed for localization of the isthmus of the arrythmia circuit in mitral isthmus. Despite of multiple radiofrequency energy applications (45 W, irrigation flow 30 ml/min, 45℃) in this area, no change in cycle length or termination of the arrhythmia was achieved (Figure 3).Based on the findings from subsequent electrophysiological studies, where optimal entrainment was observed in both distal and medial coronary sinus and ineffective endocardial aplications, an epicardial localisation of critical isthmus isolated from endocardial site was suspected. After obtaining access through the coronary sinus ostium, several applications of 30W RF energy were delivered inside distal part of the coronary sinus, guided by entrainment criteria. This approach initially resulted in the prolongation of the arrhythmia, ultimately leading to its termination. The bidirectional block in mitral isthmus was proven in the end of procedure.CONCLUSION AND RESULTSAfter 6 months follow -up, in the registered 30-day Holter monitoring study, no episodes of atrial fibrillation were recorded. The palpitations did not recur during this period. This case highlights both the feasibility of epicardial ablation in atypical AFL and the possibility of using CT to avoid TEE in high risk patients.DISCUSSIONIn conclusion, the safety of left atrial ablation largely depends on the effective exclusion of thrombi in the LAA, and in situations where TEE is contraindicated, it is worthwhile to consider the use of CT as an alternative risk assessment method.To date, epicardial access via the coronary sinus has primarily been reserved for the ablation of specific accessory pathways [2]. However, the increasing number of patients with atypical atrial flutter may necessitate an expansion of the indications for such procedures, especially in case of unsuccesful endocardial ablation [3][4].Key words: atypical atrial flutter, coronary sinus, achalasia of the esophagusAuthor Contributions:Marcin Wita MD, PhD: Conceptualization, Data curation, Writing – original draft, Investigation, Project administrationAndrzej Hoffmann MD, PhD: Conceptualization, Writing – original draft, InvestigationMateusz Polak MD, PhD: Formal analysis, SoftwareMagdalena Dobrolińska MD, PhD: Visualization , Writing – original draftBartłomiej Stasiów MD, PhD: Visualization, InvestigationAnna Pyszna-Wita PhD: Visualization, InvestigationDankowski Jakub: Conceptualization, VisualizationMichal Wita PhD: SoftwareMaciej T. Wybraniec MD, PhD, Professor: Supervision, Writing – review & editingKatarzyna Mizia – Stec MD, PhD, Professor: Supervision, Project administrationAll authors have read and agreed to the published version of the manuscript.REFERENCESNakatani Y, Sudo T, Suzuki J, Take Y, Takizawa R, Yoshimura S, Naito S. Cryoballoon ablation for atrial fibrillation in a patient with esophageal dilatation due to achalasia. HeartRhythm Case Rep. 2023 Apr 20;9(7):461-464. doi: 10.1016/j.hrcr.2023.04.010. PMID: 37492040; PMCID: PMC10363462.Marijon E, Albenque JP, Combes N, Boveda S. Use of the left coronary sinus of Valsalva for left anterior accessory pathway catheter ablation. Europace. 2009 Jun;11(6):831-3. doi: 10.1093/europace/eup096. Epub 2009 Apr 23. PMID: 19389791.Chugh A, Oral H, Good E, Han J, Tamirisa K, Lemola K, Elmouchi D, Tschopp D, Reich S, Igic P, Bogun F, Pelosi F Jr, Morady F. Catheter ablation of atypical atrial flutter and atrial tachycardia within the coronary sinus after left atrial ablation for atrial fibrillation. J Am Coll Cardiol. 2005 Jul 5;46(1):83-91. doi: 10.1016/j.jacc.2005.03.053. PMID: 15992640.Tonet J, De Sisti A, Amara W, Frank R, Hidden-Lucet F. Radiofrequency ablation of coronary sinus-dependent atrial flutter guided by fractionated mid-diastolic coronary sinus potentials. J Interv Card Electrophysiol. 2010 Nov;29(2):97-107. doi: 10.1007/s10840-010-9504-6. Epub 2010 Sep 4. PMID: 20814733; PMCID: PMC2949572.Fig 1. ECG before an ablation (a), after successful ablation (b)Fig 2. Left atrial appendage scanned immediately after contrast injection (a) and in delayed phase (b), showing no signs of thrombus.Fig 3. Radiofrequency ablation in the coronary sinus resulting in the termination of arrhythmia, as recorded on the ECG.
