case_images: PMC10794873_01
case_images: Twelve-lead electrocardiograms during atrial fibrillation (A) and 1 year post ablation (B).
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case_images: A 73-year-old male patient with a history of hypertension, diabetes mellitus, heart failure, dyslipidaemia, and a cerebral infarction was admitted to our hospital to undergo an ablation of paroxysmal AF (Figure 1A). The patient remained stable without any symptoms or AF recurrence 1 year post ablation (Figure 1B).
case_images: A computed tomography projection in the oblique axial view presents the inferior pulmonary veins entering the left atrium via a common ostium (asterisk in A). A volume-rendered three-dimensional computed tomography image of the common ostium of the right and left inferior pulmonary veins (B) and the endoscopic view from the front (C) and the left (D) demonstrate the presence of a large common inferior trunk of the pulmonary veins arising from the posterior wall of the left atrium. The EnSite  images viewed from the back before (E) and after (F and G) ablation using a third-generation (X3) laser balloon for the three pulmonary veins. The white dotted lines represent the ablation lines of the X3-LB, which were deduced from the findings seen in Figure 3E-H. LSPV, left superior pulmonary vein; RSPV, right superior pulmonary vein; Lt. br, left branch; Rt. br, right branch.
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case_images: Prior to the procedure, a contrast-enhanced cardiac computed tomography (CT) revealed an atypical PV, wherein the right and left superior PVs had normal separate ostia, while the two right and left inferior PVs had a common ostium, exhibiting a CIT (Figure 2A-C). The LA and three PVs were reconstructed using a three-dimensional (3D) mapping system (EnSite , Abbott) with a circular mapping catheter (Optima , Abbott) and the LA was confirmed to have an almost normal voltage (Figure 2E). Finally, the complete extensive electrical isolation of the three PVs, including that of the right-sided and left-sided PV carinas, was achieved without any complications (Figure 2F and G).
case_images: The fluoroscopic images demonstrate that the third-generation (X3) laser balloon (X3-LB) was positioned at the ostium of the right (A) and left (B) superior pulmonary veins and the right (C) and left (D) branches of the common inferior trunk. The endoscopic views of the right (E) and left (F) superior pulmonary veins and the common inferior trunk with the X3-LB positioned at the ostium of the right (G) and left (H) branches of the common inferior trunk. The arrows demonstrate the line of the laser energy administration. LSPV, left superior pulmonary vein; RSPV, right superior pulmonary vein; Lt. br, left branch; Rt. br, right branch.
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case_images: A temperature probe (Esophaster , Japan Lifeline) for monitoring the oesophageal temperature was inserted and placed between the levels of the left superior PV and the CIT, and a deflectable catheter, a BeeAT  (Japan Lifeline), was placed in the coronary sinus and right atrium (Figure 3A-D). LB (HeartLight X3 Catheter , CardioFocus) was navigated to the target right (Figure 3A) and left (Figure 3B) superior PVs using a 12F sheath and inflated for an optimal PV occlusion at an antral balloon position. Laser energy was deployed individually, with a 30-50% overlap in the manual energy mode. The rapid mode is continuously delivered and is not defined by this overlap percentage (Figure 3E and F). Next, the X3-LB was positioned at the ostium of the right branch of the CIT (Figure 3C) and inflated for optimal PV occlusion at the antral balloon position. CIT revealed that the right side of the LB came into complete contact with the right-sided antrum of the CIT, but the left side of the LB was in contact with the posterior wall of the CIT (Figure 3G). Conversely, the X3-LB was positioned at the ostium of the left branch of the CIT (Figure 3D) and inflated for optimal PV occlusion at the antral balloon position. The endoscopic view of the left branch of the CIT revealed that the left side of the LB came into complete contact with the left-sided antrum of the CIT, but the right side of the LB was in contact with the posterior wall of the CIT (Figure 3H). Thus, the laser energy was then individually deployed to the right-sided (Figure 3G) and left-sided (Figure 3H) antra of the CIT with the X3-LB positioned at the ostium of the CIT's right (Figure 3C) and left (Figure 3D) branches.