case_images: PMC11718516_01
case_images: The fluoroscopic image (A) demonstrates the ablation catheter placed on the cavo-tricuspid isthmus. CS, coronary sinus; Eso, oesophageal temperature probe; HRA, high right atrium; TA, tricuspid annulus. Left anterior oblique caudal view of the 3D anatomical mapping (CARTO3TM, Johnson&Johnson) (B). The tags indicate the points where the radiofrequency energy was deployed.
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case_images: One year earlier, he had undergone a CTI ablation for CTI-dependent atrial flutter (Figure 1A and B). ThermoCool SmartTouchTM Surround Flow catheter (Johnson&Johnson) with impedance of 90-110 Omega, maximum temperature set to 43 C, and a maximum power of 35 W, in the paraseptal region of the CTI (Figure 1A and B). The RF application was delivered for 20-30 s per point. Intravascular ultrasound (IVUS) images (Figure 4B-E) revealed significant stenosis with a minimal luminal area of 1.24 mm2 (Figure 4C), corresponding to the site of the CTI ablation (Figures 1A and B and 4A).
case_images: 3D coronary computed tomography imaging shown in the left anterior oblique view (A), straight view of the right coronary artery (B), and trans-axis cross-sectional view at the level of the cavo-tricuspid isthmus (CTI) ablation line (C) before the cavo-tricuspid isthmus ablation. IVC, inferior vena cava; RA, right atrium; RCA, right coronary artery; RV, right ventricle; TV, tricuspid valve.
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case_images: RFA had shown no significant CA stenosis (Figure 2A and B). Retrospectively, the minimum distance between the RCA and CTI ablation line was 1.6 mm (Figure 2C). Radiofrequency (RF) energy was applied with a
case_images: The 12-lead electrocardiograms after ablation 1 year previously (A) and on admission (B). The electrocardiogram during exercise stress testing (C).
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case_images: A 12-lead electrocardiogram after RFA revealed sinus rhythm with no ST-T changes (Figure 3A). A 12-lead electrocardiogram revealed sinus rhythm with new T inversions in leads III and aVF (Figure 3B). His exercise stress testing showed a downward sloping ST-segment depression exceeding 0.2 mV in leads II, III, aVF, V5, and V6 (Figure 3C) accompanied by chest pain, indicative of effort angina pectoris.
case_images: The coronary angiogram of the right coronary artery in the left anterior oblique view (B). The intravascular ultrasound (IVUS) images (B-E) reveal a significant stenosis (C, D), which corresponds to the site of the cavo-tricuspid isthmus ablation. Intravascular ultrasound also demonstrated that this stenotic lesion primarily consisted of heterogeneous fibrous plaque (solid arrows) including few echolucent lesions (dashed arrows).
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case_images: CVD risk score was moderate. Coronary angiography revealed 90% severe stenosis at the distal site of the RCA (Figure 4A), whereas the left CA appeared normal. Intravascular ultrasound (IVUS) images (Figure 4B-E) revealed significant stenosis with a minimal luminal area of 1.24 mm2 (Figure 4C), corresponding to the site of the CTI ablation (Figures 1A and B and 4A). Intravascular ultrasound also demonstrated that the stenotic lesion primarily consisted of a heterogeneous fibrous plaque (solid arrows in Figure 4B-E), including few echolucent lesions (dashed arrows in Figure 4C) indicate healed plaque. There were no echo-attenuated plaques (Figure 4B-E).