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255 sheath (FlexCath, Medtronic). The occlusion of each vein was confirmed after contrast in‐ jection (FIGURE 1C–1F). Remarkably, due to proper occlusion, the ostia were altered to a more cir‐ cular shape (compliant with the cryoballoon), which was more prominent in the right veins compared with the left ones (25% vs 10.2%). The application sequence was LSPV–LIPV–RSPV– RIPV. A single cryoapplication (180 s) was de‐ livered to isolate each vein. The temperature nadir was –49 oC at 151 s of freeze in the LSPV (OI, 2.2), –48 oC at 134 s in the LIPV (OI, 1.7), –45 oC at 155 s in the RSPV (OI, 1.5), and –54 oC at 146 s in the RIPV (OI, 1.3). In order to avoid phrenic nerve palsy, diaphragmatic stimulation from the right subclavian vein was performed during right ‐sided cryoapplications. Consid‐ ering the high OI, a dedicated guidewire (PV‐ ‐tracker, Medtronic) advanced to the distal part of the vein was used for the cryoballoon posi‐ tioning to obtain optimal stability. Consequent‐ ly, bidirectional electrical isolation in all PVs was confirmed with a decapolar mapping cath‐ eter (Inquiry, Abbott, Minneapolis, Minneso‐ ta, United States). Typically, left PVs have higher OI compared with the right ones,3 which was observed in our case. A high OI impedes adequate vein occlu‐ sion and may lead to worse short‐ and long‐ ‐term outcomes. This relationship was clearly defined for the LSPV.4 More oval PVs are associ‐ ated with frequent AF recurrence.5 In our patient, the PVs (except for the RIPV) were extremely flat, but we achieved good occlusion and adequate Cryoballoon ablation has become a standard treatment in the management of atrial fibril‐ lation (AF).1 The ovality index (OI) of the pul‐ monary veins (PVs) is one of the factors that may affect the efficiency of cryoballoon abla‐ tion. It is defined as a ratio of the maximum to the minimum diameter of the PV ostium. Veins are usually classified as circular (OI <1.2), oval (OI, 1.2–1.4), or flat (OI >1.4).2 We report a case of a 53‐year ‐old man with persistent AF and extremely flat PVs (mean OI, 1.675) who was referred to our department for PV isolation. Preprocedural computed tomography re‐ vealed a typical configuration of 4 PVs with the following diameters (longitudinal × trans‐ verse): left superior PV (LSPV), 22 × 10 mm; left inferior PV (LIPV), 22 × 13 mm; right superi‐ or PV (RSPV), 27 × 18 mm; and right inferior PV (RIPV), 23 × 18 mm (FIGURE 1A and 1B). Further‐ more, it showed left atrial volume of 250 ml, the cauliflower ‐like left atrial appendage, and normal coronary arteries. On transthorac‐ ic echocardiography, left ventricular ejection fraction was 52%, and the left atrial diameter, 36 mm. Cryoballoon PV isolation was conducted un‐ der conscious sedation. After a single trans‐ septal puncture (with the BRK‐1XS needle [Ab‐ bott, St. Paul, Minnesota, United States]) per‐ formed under fluoroscopic guidance, a 28‐mm cryoballoon (AF Advance ST, Medtronic, Min‐ neapolis, Minnesota, United States) was in‐ troduced into the left atrium using a steerable Correspondence to: Andrzej Głowniak, MD, PhD, Department of Cardiology, Medical University of Lublin, ul. Jaczewskiego 8, 20-090 Lublin, Poland, phone: +48 81 724 41 51, email: andrzej.glowniak@gmail.com Received: October 11, 2019. Revision accepted: January 15, 2020. Published online: January 16, 2020. Kardiol Pol. 2020; 78 (3): 255-256 doi:10.33963/KP.15144 Copyright by the Author(s), 2020 C L I N I C A L V I G N E T T E

Effective isolation of pulmonary veins with extremely high ovality index using a third‑generation cryoballoon catheter