case_images: PMC11730988_01
case_images: Steps in Right atrium to Left ventricle puncture. (A) Puncture of the inferior RA septum using cautery; (B) Once puncture was made, the 0.032 mm wire was inserted through the puncture site and into the LV; (C) The 0.032 wire was replaced with steel wire; (D) The steel wire was exchanged with Boston Scientific V-18 Control wire. The ST-01 catheter was changed with Boston Scientific Mustang Balloon and placed into the puncture site and several dilatations were done; (E) Balloon catheter and control wire removed; Mapping catheter placed inside the LV; (F) ICE at inferolateral RA. The 0.032 wire was positioned at inferior RA septum and visualized as it punctured into the LV. ICE, intracardiac echocardiography; LV, left ventricle: RA, right atrium.
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case_images: With the intracardiac echocardiography (ICE) placed in the RA, we could visualize the CS, left ventricle (LV), and tricuspid valve (Figure 1F). The 0.032 wire and ST-01 catheter were advanced into the puncture site (Figure 1B). The 0.032 wire was replaced with steel wire (Figure 1C) and was exchanged for a Boston Scientific Control wire (Figure 1D). The ST-01 was changed with a Boston Scientific Mustang balloon catheter (Figure 1D). Agilis was inserted into the LV with the dilator. Afterwards, the mapping catheter was positioned in the LV (Figure 1E), where late potentials were identified at the LV basal septum (Figure 3C).
case_images: Schematic illustration and 3D image of Puncture site. (A) Schema Koch's triangle and puncture site. The Koch's triangle was viewed in RAO 30 during the procedure. The Agilis (light orange) was placed in the inferomedial right atrium (RA) anterior to the CS ostium. The 0.032 wire (red line) is inserted in the Agilis and the tip is positioned at the inferomedial RA (blue star). The tip of the guidewire was applied with cautery energy while the other end of the guidewire is maintained at the puncture site in RA. (B) 3D image of Right atrium to left ventricle puncture site. AV, aortic valve; CS, coronary sinus; MV, mitral valve.
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case_images: joa313186-fig-0002
case_images: A schema of Koch's triangle and puncture site is provided in Figure 2A. The puncture site can also be seen using 3D image as seen in Figure 2B.
case_images: 12 L EKG and intracardiac recordings during the procedure with ablation lesions on 3D. (A) 12 lead electrocardiogram of Ventricular Tachycardia induced during the right atrium to left ventricle puncture with tachycardia cycle length 284 ms, RBBB, superior axis and terminated with cardioversion. (B) Ablation lesions. Post ablation voltage map with ablation lesions on left ventricular septum. Red tags are ablation lesions. Color coding settings for bipolar voltage from 0.50 mV(red) to 1.50 mV(magenta). (C) Example of late potentials as seen on the decapolar mapping catheter (Deca 1-2 and 3-4) during pacing at the left ventricle (LV), particularly at basal septum in this tracing. Decapolar mapping catheter was positioned at LV basal septum.
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case_images: During the puncture, VT was induced with right bundle branch block (RBBB) morphology and superior axis, which was terminated with cardioversion (Figure 3A). Agilis was inserted into the LV with the dilator. Afterwards, the mapping catheter was positioned in the LV (Figure 1E), where late potentials were identified at the LV basal septum (Figure 3C). Ablation was conducted at the VT exit, and we homogenized the area as seen in Figure 3B with local abnormal ventricular activities (LAVAs) during sinus rhythm or ventricular pacing according to our protocol. 
case_images: Transthoracic echocardiography 3 days after procedure showing shunt on puncture site.
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case_images: On repeat echocardiography (Figure 4) 3 days during hospitalization and 1 month after discharge, a residual shunt was still noted with a Qp/Qs of 1.9 before and after the procedure but it seems that the Qp/Qs estimation via echocardiography might be an overestimate, which is a limitation to this case.