Ongoing substrate-driven atrial fibrillation “boxed” in the left atrial posterior wall with ablation: a case report

Patients undergoing valve surgery for rheumatic heart disease are expected to develop significant atrial arrhythmogenic substrates outside of the pulmonary veins, which sometimes require complex ablation techniques treatment symptomatic arrhythmias. We describe, herein, case a 76-year-old male endocardial persistent fibrillation developed after aortic and mitral replacement with simultaneous tricuspid ring annuloplasty. Following vein isolation, patient's was converted into cavotricuspid isthmus-dependent flutter. After successful isthmus ablation, arrhythmia reverted back left tachyarrhythmia originating from posterior wall. A linear lesion led electrical isolation large area, included wall, as well containment ongoing fibrillatory activity, while sinus rhythm restored in rest atria. In conclusion, wall can be achieved setting severe scarring due previous atriotomy by creating on roof, conjunction sparing patient requiring bottom-line avoiding possible esophageal injury. Such compartmentalization atrium may effectively contain local allowing restoration rhythm.