Radiofrequency ablation for paroxysmal atrial fibrillation in a patient with dextrocardia and interruption of the inferior vena cava: a case report

Abstract Background Dextrocardia with interruption of the inferior vena cava (I-IVC) is a very rare anatomical variant. Catheter ablation of atrial fibrillation (AF) in patients with this anatomical variant is challenging for electrophysiologists. This case report presents a safe, effective, and radiation-free approach for high-power ablation of AF via a superior transseptal approach in patients with dextrocardia and I-IVC. Case summary A 57-year-old man with paroxysmal AF with dextrocardia and I-IVC with azygos continuation was referred to our hospital for radiofrequency (RF) ablation. It was evident that transseptal puncture and pulmonary vein isolation (PVI) would be impossible using an IVC approach via the femoral vein. Therefore, we decided to perform left atrium (LA) ablation via the superior vena cava approach. A phased array intracardiac echocardiography (ICE) catheter was inserted in the right femoral vein. Three-dimensional (3D) anatomical reconstruction of LA, right atrium (RA), and coronary sinus (CS) ostium were performed using ICE with azygos vein and RA imaging. Navigation-enabled electrodes were inserted into annotated CS on cardiac 3D ICE image. The left internal jugular vein was accessed using an SL1 transseptal sheath and Brockenbrough needle. Transseptal puncture was performed under ICE with an RF-assisted approach. We accomplished ablation index guided high-power pulmonary vein isolation using a bi-directional guiding sheath with visualization capabilities and a surround flow contact force-sensing catheter. No complications occurred during or after the procedure. Discussion With the application of multitude of newer technologies, we can accomplish safe, effective, and fluoroscopy-free RF ablation of AF using the superior approach in patients with complex anomaly.

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A case report of pulmonary vein isolation with radiofrequency catheter using superior vena cava approach in patient with paroxysmal atrial fibrillation and inferior vena cava filter

European Heart Journal - Case Reports ◽

10.1093/ehjcr/ytaa562 ◽

2021 ◽

Vol 5 (2) ◽

Author(s):

Masatoshi Narikawa ◽

Masayoshi Kiyokuni ◽

Junya Hosoda ◽

Toshiyuki Ishikawa

Keyword(s):

Atrial Fibrillation ◽

Inferior Vena Cava ◽

Left Atrium ◽

Inferior Vena ◽

Superior Vena ◽

Vena Cava ◽

Ivc Filter ◽

Transseptal Puncture ◽

Mapping Catheter ◽

Steerable Sheath

Abstract Background Transseptal puncture and pulmonary vein isolation (PVI) in patients with atrial fibrillation (AF) are generally performed via the inferior vena cava (IVC). However, in cases where the IVC is inaccessible, a specific strategy may be needed. Case summary An 86-year-old woman with paroxysmal AF and an IVC filter in situ was referred to our hospital for ablation therapy. An IVC filter for pulmonary embolism and deep venous thrombosis had been implanted 15 years prior, therefore we selected a transoesophageal echocardiography (TOE)-guided transseptal puncture using a superior vena cava (SVC) approach. After the single transseptal puncture, we performed fast anatomical mapping, voltage mapping by multipolar mapping catheter, and then PVI by contact force-guided radiofrequency catheter using a steerable sheath. Following the ablation, bidirectional conduction block between the four pulmonary veins and the left atrium was confirmed by both radiofrequency and mapping catheter. No complications occurred and no recurrence of AF was documented in the 12 months after the procedure. Discussion When performing a transseptal puncture during AF ablation, an SVC approach, via access through the right internal jugular vein, enables the sheath to directly approach the left atrium without angulation and improves operability of the ablation catheter. Combining the use of general anaesthesia, TOE, a steerable sheath, and contact force-guided ablation may contribute to achieving minimally invasive PVI with a single transseptal puncture via an SVC approach.

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Transseptal puncture and catheter ablation via the superior vena cava approach for persistent atrial fibrillation in a patient with polysplenia syndrome and interruption of the inferior vena cava: contact force–guided pulmonary vein isolation

EP Europace ◽

10.1093/europace/euw095 ◽

2016 ◽

pp. euw095

Author(s):

Hiroshi Kato ◽

Shoichi Kubota ◽

Takuya Goto ◽

Koichi Inoue ◽

Naohiko Oku ◽

...

Keyword(s):

Atrial Fibrillation ◽

Catheter Ablation ◽

Inferior Vena Cava ◽

Pulmonary Vein ◽

Superior Vena Cava ◽

Inferior Vena ◽

Superior Vena ◽

Vena Cava ◽

Persistent Atrial Fibrillation ◽

Transseptal Puncture

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Hepatocellular carcinoma tumor thrombus entering the inferior vena cava treated with percutaneous RF ablation: a case report

Journal of Ultrasound ◽

10.1007/s40477-019-00361-w ◽

2019 ◽

Vol 22 (3) ◽

pp. 363-370 ◽

Cited By ~ 1

Author(s):

Pietro Gatti ◽

Antonio Giorgio ◽

Emanuela Ciracì ◽

Italia Roberto ◽

Alessandro Anglani ◽

...

Keyword(s):

Hepatocellular Carcinoma ◽

Case Report ◽

Inferior Vena Cava ◽

Tumor Thrombus ◽

Inferior Vena ◽

Vena Cava ◽

Rf Ablation ◽

Carcinoma Tumor

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Transseptal puncture from the jugular vein and balloon cryoablation for atrial fibrillation in a patient with azygos continuation of an interrupted inferior vena cava

EP Europace ◽

10.1093/europace/euu413 ◽

2015 ◽

Vol 17 (7) ◽

pp. 1153-1156 ◽

Cited By ~ 9

Author(s):

Artur Baszko ◽

Piotr Kałmucki ◽

Rafał Dankowski ◽

Magdalena Łanocha ◽

Tomasz Siminiak ◽

...

Keyword(s):

Atrial Fibrillation ◽

Inferior Vena Cava ◽

Inferior Vena ◽

Jugular Vein ◽

Vena Cava ◽

Transseptal Puncture ◽

Azygos Continuation

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Balloon Mitral Valvotomy in Pregnant Patient with Anomalous Inferior Vena Cava

Asian Cardiovascular and Thoracic Annals ◽

10.1177/021849239800600319 ◽

1998 ◽

Vol 6 (3) ◽

pp. 227-228

Author(s):

Manoj K Agarwala ◽

Mandeep Singh ◽

Anil Grover ◽

Jagmohan S Varma

Keyword(s):

Inferior Vena Cava ◽

Mitral Stenosis ◽

Inferior Vena ◽

Femoral Vein ◽

Vena Cava ◽

Pregnant Patient ◽

Transseptal Puncture ◽

Balloon Valvotomy ◽

Anomalous Inferior Vena Cava ◽

Mitral Valvotomy

Successful balloon valvotomy was performed by the Inoue technique in a pregnant lady with severe mitral stenosis and pulmonary edema. Total pelvic and abdominal shielding was used and a transseptal puncture was carried out through the left femoral vein because of an anatomically anomalous course of the inferior vena cava.

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Percutaneous transhepatic access for catheter ablation of A patient with heterotaxy syndrome complicated with atrial fibrillation ：a case report

10.22541/au.163263249.99117081/v1 ◽

2021 ◽

Author(s):

Na Li ◽

Haixiong Wang ◽

xue Han ◽

jian An

Keyword(s):

Atrial Fibrillation ◽

Case Report ◽

Catheter Ablation ◽

Inferior Vena ◽

Femoral Vein ◽

Vena Cava ◽

Heterotaxy Syndrome ◽

Surgical Ligation ◽

Vein Access ◽

Transhepatic Access

Atrial fibrillation (AF) is one of the most common arrhythmia, and radiofrequence catheter ablation has become the most effective treatment method.The inferior vena cava(IVC)is a common approach for radiofrequency ablation of atrial fibrillation. In some cases, this approach cannot be used, such as chronic venous occlusions, surgical ligation of the IVC and heterotaxy syndrome. In patients without femoral vein access, use of the hepatic vein for PVI is a viable alternative for invasive EP procedures.

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Modified Mini-Maze for Atrial Fibrillation with Interruption of Inferior Vena Cava

The Heart Surgery Forum ◽

10.1532/hsf.4163 ◽

2021 ◽

Vol 24 (6) ◽

pp. E1046-E1048

Author(s):

Bijun Xu ◽

Fan He ◽

Shiqiang Wang ◽

Huaidong Chen ◽

Weimin Zhang

Keyword(s):

Atrial Fibrillation ◽

Inferior Vena Cava ◽

Left Atrium ◽

Inferior Vena ◽

Thoracoscopic Surgery ◽

Femoral Vein ◽

Vena Cava ◽

Maze Procedure ◽

Cardiac Ganglia ◽

Video Assisted Thoracoscopic Surgery

A 57-year-old female with paroxysmal atrial fibrillation and an interrupted inferior vena cava (IVC) was referred to our hospital for radiofrequency ablation. Transseptal puncture and left atrium ablation failed through a standard IVC approach via the femoral vein due to intrahepatic interruption of IVC. We performed a modified mini-maze procedure in this patient through the left thoracic cavity under video-assisted thoracoscopic surgery (VATS). We can successfully complete pulmonary vein (PV) isolation, left atrium box isolation, cardiac ganglia ablation, Marshall ligament ablation, and coronary sinus epicardium ablation using this technique.

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A case report of pulmonary vein isolation performed in a patient with polysplenia and interrupted inferior vena cava

European Heart Journal - Case Reports ◽

10.1093/ehjcr/ytab480 ◽

2021 ◽

Author(s):

Kaspars Kupics ◽

Kristine Jubele ◽

Georgijs Nesterovics ◽

Andrejs Erglis

Keyword(s):

Inferior Vena Cava ◽

Pulmonary Vein ◽

Pulmonary Vein Isolation ◽

Inferior Vena ◽

Femoral Vein ◽

Pulmonary Veins ◽

Vena Cava ◽

Venous Access ◽

University Hospital ◽

Anatomical Variant

Abstract Background Pulmonary vein isolation (PVI) has entrenched itself as one of main approaches for treatment of paroxysmal symptomatic atrial fibrillation (AF). PVI prevents focal triggers from pulmonary veins from initiating AF paroxysms. As standard—PVI is performed through the inferior vena cava (IVC) approach, through the femoral vein. However, there are conditions when this approach is not appropriate or is not available. Case summary We report a case of a 53-year-old male who was referred to Pauls Stradins Clinical University Hospital for PVI due to worsening AF. Due to the rare anatomical variant of the venous system the standard approach to PVI could not be applied. Interrupted cava inferior did not allow for femoral vein and IVC access. We had to figure out a different path—a combination of internal jugular and subclavian veins was used. Transseptal puncture was performed under transesophageal echocardiography (TOE) control with a puncture needle stiletto. Pulmonary veins were isolated successfully, no complications were observed, and the patient was discharged in sinus rhythm. Discussion In some patients PVI cannot be done through the standard IVC approach. In such cases a different venous access must be chosen. Our patient had a rare variant of interrupted IVC and we had to use superior vena cava approach for the procedure. The difficulty of this approach is that procedure instruments are not designed for non-standard venous access, however a combined use of TOE, general anaesthesia and contact force guided ablation has succeeded in isolating patients’ pulmonary veins.

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