Soundstar

After confirming the anatomic position of the esophagus by asking patients to swallow contrast medium, all patients underwent the catheter ablation procedure in the fasting state under local anesthesia and conscious sedation with dexmedetomidine and thiamylal. Respiratory management devices, such as a nasal airway device and adaptive servo ventilation, were used at the operator’s discretion. A 6-Fr, double-decapolar, steerable catheter (BeeAT; Japan Lifeline, Tokyo, Japan) was inserted into the coronary sinus via the right internal jugular vein. An 8-Fr SoundStar ultrasound catheter (Biosense Webster) was inserted into the right atrium (RA) via the right femoral vein and the anatomy of the LA was mapped using the CartoSound module in the CARTO3 system. After transseptal puncture under intracardiac echocardiography, 2 8.5-Fr long sheaths (SL0; St. Jude Medical, St. Paul, MN, USA) were inserted into the LA. In patients with persistent AF, an 8.5-Fr deflectable sheath (Agilis; St. Jude Medical) was used at the operator’s discretion. Patients were injected with 3,000 units heparin before the transseptal puncture, with an addition 5,000 units heparin immediately after the transseptal puncture, followed by repetitive injection of 1,000–2,000 units heparin to maintain an activated clotting time >300 s during the procedure.

All antiarrhythmic drugs were discontinued depending on patient characteristics and at the discretion of the operator. All patients underwent general endotracheal intubation and low volume, high frequency ventilation. Transeptal puncture was guided by intracardiac echocardiography (ICE) and 3D electroanatomic mapping (EAM; Biosense Webster, Diamond Bar, CA, USA). Fluoroscopy was only used to locate the esophageal temperature probe and in patients with tortuous venous anatomy. Using ultrasound guidance and a modified Seldinger technique, three sheaths were placed into the right femoral vein (RFV). A weight-based heparin bolus was administered prior to transseptal puncture. Activated clotting time (ACT) was monitored throughout the procedure, and intravenous heparin bolus was administered to target ACT >350 seconds prior to and after transseptal puncture. A 10F ICE catheter (SoundStar; Biosense Webster, Diamond Bar, CA, USA), a 3.5mm irrigated ablation catheter (SmartTouch STSF; Biosense Webster, Diamond Bar, CA, USA) were introduced into the right atrium (RA). EAM was used to create geometry of the RA, superior and inferior vena cavae, coronary sinus (CS), transseptal puncture location and LA. A decapolar diagnostic catheter (Inquiry; Abbott) was inserted into the coronary sinus using EAM guidance (CARTO 3; Biosense Webster).