Pulmonary vein isolation in a patient with atrial fibrillation and a filter in the inferior vena cava

Abstract Introduction Congenital anomalies of the inferior vena cava (IVC) are a well described entity. These anomalies include complete absence, partial absence or duplication of the IVC. They are seen more frequently in those with other congenital cardiac anomalies (0.6%–2%). This congenital condition can be discovered incidentally, or due to symptoms of associated congenital heart disease, asplenia, polysplenia, congenital kidney anomalies or deep venous thrombosis. Case report We report the case of a 48 years old man scheduled for pulmonary vein isolation due to persistent atrial fibrillation resistant to antiarhythmic drugs, symptomatic for palpitations and dyspnea on exertion. Transthoracic ecgocardiography showed mild left atrium enlargement, normal systolic LV function and no significant valve disease. The transoesophageal echocardiography revealed dilation of the left atrium and absence of thrombus in the left atrium or left appendage. Multi-slice spiral thoracic computed tomography (MSCT) was also performed before the procedure and revealed absence of the inferior vena cava and significant dilation of the azygos and hemiazygos veins with subsequent drainage into the superior vena cava. Abdominal CT showed also partial situs inversus. Pulmonary vein isolation (PVI) through femoral vein approach was cancelled and the patient was scheduled for remote magnetic navigation PVI through arterial approach. Conclusions Whether the absence of the IVC is an embryonic anomaly or the result of perinatal thrombosis with regression and subsequent congenital absence of the IVC, absence of the IVC creates difficulties for catheter ablation of arrhythmias via the femoral vein approach.

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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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Ultrasound Diagnosis of Congestion in the Pulmonary and Systemic Circulations in Patients with Atrial Fibrillation and Chronic Heart Failure

10.21203/rs.3.rs-390567/v1 ◽

2021 ◽

Author(s):

Venera Kirillova ◽

Andrey Smorgon ◽

Alla Garganeeva ◽

Roman Batalov ◽

Viktor Meshchaninov ◽

...

Keyword(s):

Heart Failure ◽

Atrial Fibrillation ◽

Chronic Heart Failure ◽

Inferior Vena Cava ◽

Pulmonary Vein ◽

Inferior Vena ◽

Vena Cava ◽

Average Pressure ◽

Superior Pulmonary Vein ◽

The Right

Abstract BackgroundFluid retention is one of the most common reasons for the heart failure decompensation. The purpose of the study is to estimate the sensitivity, specificity of the ultrasound method for evaluating congestive phenomena in the systemic and pulmonary circulations in patients with the atrial fibrillation (AF) and chronic heart failure (CHF).MethodsThe study includes 28 patients with the paroxysmal AF with and without CHF, who were planned for the radiofrequency pulmonary veins isolation. The maximum and minimum diameters of the right superior pulmonary vein and inferior vena cava on exhalation were measured echocardiographically. An average pressure in the right and left atria was measured intraoperatively. Сorrelation between the maximum and minimum diameters of the right superior pulmonary vein and an average pressure in the left atria and between inferior vena cava on exhalation and an average pressure in the right atria was calculated. The sensitivity, specificity of ultrasound methods for evaluating congestive phenomena in the systemic and pulmonary circulations was evaluated.ResultsThere was positive correlation between the minimum diameter of right superior pulmonary vein and invasive mean pressure in the left atrium (R=0.65, P<0.05), between invasive measured mean pressure in the right atrium and the diameter of the inferior vena cava on exhalation (R=0.49, P<0.05). Sensitivity of the method – maximum diameters of the right superior pulmonary vein greater than 21.7 mm are ultrasound criteria for venous pulmonary hypertension is 75%, specificity – 86%. Sensitivity of the method minimum diameters of the right superior pulmonary vein greater than 10.5 mm are ultrasound criteria for venous pulmonary hypertension is 85%, specificity – 86%. The sensitivity of the inferior vena cava diameter exceeding 18,5 mm on exhalation is 100%, the specificity is 92%.ConclusionsThe new ultrasound method of congestion diagnostics in the pulmonary circulation by the maximum and/or minimum diameter of the right superior pulmonary vein can be effectively applied in clinical practice in the same way as the well-known technique of congestion diagnostics in the systemic circulation by the diameter of the inferior vena cava in patients with the atrial fibrillation and chronic heart failure.

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Response to flecainide infusion predicts long-term success of inferior vena cava-tricuspid annulus ablation in patients with atrial fibrillation

EP Europace ◽

10.1016/s1099-5129(01)80075-1 ◽

2001 ◽

Vol 2 ◽

pp. A7-A7

Keyword(s):

Atrial Fibrillation ◽

Inferior Vena Cava ◽

Inferior Vena ◽

Vena Cava ◽

Tricuspid Annulus

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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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