The right and left femoral veins were cannulated with a thin-walled 18-gauge needle through which a J-tipped guidewire was passed. Two guidewires were placed in the left femoral vein and two guidewires were placed in the right femoral vein. Two 7 French introducers were advanced over the guidewires in the left femoral vein. Two 8 French introducers were advanced over the guidewires in the right femoral vein. The guidewires and dilators were removed. The introducers were aspirated and flushed carefully and placed on a continuous infusion of heparinized saline.
Three standard quadripolar electrode catheters were introduced in the left femoral vein and advanced to the heart under fluoroscopic guidance. These catheters were placed in the right ventricular apex and across the tricuspid valve to record His bundle potential. Steerable decapolar electrode catheters were introduced into the left femoral vein and advanced to the heart under fluoroscopic guidance. These catheters were positioned along the posterolateral aspect of the tricuspid valve annulus.
A steerable quadripolar electrode catheter was introduced into the right femoral vein and advanced to the heart under fluoroscopic guidance. This catheter was placed in the proximal coronary sinus. After the catheters were determined to be in stable position, the ablation catheter was introduced. This was a 3.5 mm irrigated tip catheter. This was initially used to perform entrainment mapping along the posterolateral aspect of the tricuspid valve annulus. Several sites were identified, most of which had returned cycle length within 15 milliseconds of the tachycardia cycle length.
Mapping was then performed along the previous ablation line. Some sites were identified, which had some early activity during atrial flutter. A series of radiofrequency energy lesions were applied. The atrial flutter was observed to terminate quite promptly. The patient from the coronary sinus, however, did demonstrate some residual isthmus conduction. A series of radiofrequency energy lesions were placed, which did interrupt the isthmus conduction. Several consolidative lesions were then placed using irrigated tipped catheter technology. Programmed stimulations were performed after restoration of sinus rhythm. After 60 minutes of observation, there was still no isthmus conduction and the lesion seemed quite solid. The procedure was then considered complete.
The catheters were removed. Venous introducers were removed. Firm manual pressures were applied over the venous puncture sites until adequate hemostasis was achieved. The patient tolerated the procedure well. There were no apparent complications.
