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Fluoroscopy‐Free PVI With nMARQTM in a Patient With a PFO

A 57-year-old patient with drug-refractory atrial fibrillation (AF) was referred to our institution for pulmonary vein isolation (PVI). Transesophageal echocardiography to rule out left atrial thrombus prior to the intervention revealed a large persistent foramen ovale (PFO; Fig. 1A). PVI was planned using an irrigated multielectrode ablation (IMEA) catheter (nMARQTM, Biosense Webster Inc., Diamond Bar, CA, USA) in combination with a 3D mapping system (Carto 3 System, Biosense Webster Inc.). Left atrial anatomy was assessed using cardiac magnetic resonance imaging prior to the procedure. A sensor-based decapolar catheter (Deca NAV, Biosense Webster Inc.) was advanced through a steerable sheath (Agilis NxTTM, St. Jude Medical, St. Paul, MN, USA) into the right atrium (RA) guided by the 3D mapping system in an anterior-posterior view. A fast anatomical map (FAM) of the RA, superior vena cava, inferior vena cava, and coronary sinus was acquired in order to localize the septum and ultimately the PFO. The PFO was anatomically mapped with the decapolar catheter in a right anterior oblique and left anterior oblique view. The deflectable sheath was then advanced into the left atrium (LA) until the distal electrodes of the decapolar catheter switched to black as a sign of the position of the catheter within the sheath, thereby proving the position of the sheath in the LA (Fig. 1B). The decapolar catheter was replaced by a 20-pole circumferential mapping catheter (Lasso NAV 2515, Biosense Webster Inc.) for acquisition of a detailed FAM of the LA including all pulmonary