Cryoballoon Ablation of the Pulmonary Veins, the Posterior Wall, the Left Atrial Appendage, and the Mitral Isthmus Guided by Intracardiac Echocardiography–integrated and Three-dimensional Mapping

Here, we describe the first reported case of pulmonary vein, posterior wall, and left atrial appendage (LAA) isolation with concomitant ablation of a mitral isthmus flutter using the cryoballoon, guided by intracardiac echocardiography (ICE)-integrated 3-dimensional mapping in a patient with long-standing persistent atrial fibrillation and intolerance to long-term oral anticoagulation, followed by ICE-guided LAA closure using an endocardial occlusion device. This report illustrates the safety and feasibility of this combined approach. Additionally, it advocates for empiric LAA isolation prior to LAA occlusion, as LAA ablation/isolation can prove challenging in those with existing endocardial LAA occlusion devices should they require subsequent ablations to target arrhythmias or triggers arising from this structure.