Atrial Septostomy to Treat Stiff Left Atrium Syndrome
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Radiofrequency ablation is an effective therapy to restore sinus rhythm in patients with symptomatic atrial fibrillation. Approximately 1.4% of patients undergoing ablation develop unexplained dyspnea because of isolated left atrial (LA) hypertension.1,2 This condition has been termed the stiff LA syndrome. Ideal treatment strategies for stiff LA syndrome remain unclear.
A 71-year-old man presented with dyspnea. He had a history of paroxysmal atrial fibrillation/flutter treated with 3 ablation procedures in the preceding 9 years. Physical examination revealed a rapid, irregular heart rate at 173 and jugular venous distention to 10 cm. ECG demonstrated atrial tachycardia. Echocardiogram demonstrated left ventricular ejection fraction of 50%, biatrial enlargement, mild mitral regurgitation, mild right ventricular enlargement, mild–moderate right ventricular systolic dysfunction, and an estimated right ventricular systolic pressure of 43 mm Hg.
He was admitted and rate controlled. However, he continued to complain of severe dyspnea after dismissal, despite diuresis. A cardiopulmonary exercise test demonstrated peak oxygen consumption (VO2) of 10.9 mL/kg/min (43% predicted), suggesting severe cardiac limitation. Chest computed tomography demonstrated normal pulmonary vein anatomy without stenosis.
Cardiac catheterization was performed with transseptal puncture (Figure 1). Right atrial pressure was mildly elevated (10 mm Hg). The …