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+A 60-year-old white Brazilian man, with controlled hypertension and stage 2 obesity presented to our institution with a complaint of progressive fatigue with moderate to light exertion of approximately 1 year’s duration.
+During that period, he had undergone myocardial perfusion scintigraphy without evidence of obstructive ischemic disease.
+He had no clinical evidence of systolic heart failure.
+He had undergone biological mitral valve replacement 3 years previously for mitral valve stenosis and had undergone ablation of atrioventricular nodal reentry tachycardia 18 months previously.
+At the time of valve replacement, there was no reported evidence of pulmonary arterial hypertension.
+The patient’s medication list included aspirin 100 mg/day, carvedilol 50 mg/day, atorvastatin 10 mg/day, and losartan 25 mg/day.
+His echocardiogram showed normal function of a mitral prosthesis, global left ventricular systolic function within normal limits (left ventricular ejection fraction 62 % measured using the Teichholz method), stage I diastolic dysfunction, and mean pulmonary arterial systolic blood pressure of 50 mmHg.
+In the 6-minute walk test, the patient walked 104 meters (Table 1).
+Catheterization of his right heart chambers and pulmonary arteries confirmed the diagnosis of pulmonary hypertension (Table 2).
+During the follow-up period, therapy with nifedipine and sildenafil was not tolerated secondary to orthostatic hypotension.
+The patient was referred for radiofrequency ablation of the pulmonary artery trunk for the treatment of refractory pulmonary hypertension.
+The procedure was performed in the catheterization laboratory with direct visualization using fluoroscopy and radiopaque contrast dye.
+The patient remained under unconscious sedation.
+Catheterization of the right femoral artery via the standard Seldinger technique was performed using an 8-French valved short sheath after subcutaneous injection of a local anesthetic.
+Subsequently, this sheath was replaced with a steerable long sheath (Agilis®; St. Jude Medical, St. Paul, MN, USA) using the standard over-the-wire technique.
+Unfractionated heparin was administered intravenously, targeting an activated coagulation time between 250 and 350 seconds.
+Electroanatomic reconstruction of both the right ventricular outflow tract and pulmonary artery was performed using the EnSite Velocity Cardiac Mapping System (St.Jude Medical) under direct fluoroscopic visualization, and a merger was made with the formatted image obtained by performing cardiac computed tomography angiography (Fig.1).
+The Agilis® sheath was advanced into the right ventricular outflow tract just before reaching the pulmonary valve.
+Through this long sheath, we introduced an ablation catheter with an open irrigated tip (St.Jude Medical).
+The parameters used for each application according to our protocol were as follows: power of 5 W, maximum temperature of 48 °C, 60-second duration in each spot, maximum impedance variation of 10 % from baseline values, and an irrigation flow rate of 17 ml/minute, which created a circle in the pulmonary artery trunk.
+The patient was discharged the next morning.
+No noteworthy changes before or after the procedure or before discharge in the patient’s radiographic or echocardiographic laboratory parameters were seen.
+The patient’s blood pressure in both the right heart chambers and the pulmonary artery were determined using catheterization before and at 3 and 6 months after the procedure.
+The results are shown in Table 2.
+At the patient’s 3-month follow-up examination, he showed an improvement in functional class for fatigue with major exertion.
+He also demonstrated an increased distance walked in the 6-minute walk test and reduction of the pressures in both the right cavities and the pulmonary artery.
+Currently, with 6 months of clinical follow-up, he has maintained his improvement in functional classification and is pedaling his bicycle.