International Journal of Cardiology 187 (2015) 235–236

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International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard

Letter to the editor

A rare localization for non-pulmonary vein trigger of atrial fibrillation: persistent left superior vena cava Dursun Aras 1, Serkan Cay ⁎,1, Serkan Topaloglu, Firat Ozcan, Ozcan Ozeke Department of Cardiology, Division of Arrhythmia and Electrophysiology, Yuksek Ihtisas Heart-Education and Research Hospital, Ankara, Turkey

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Article history: Received 17 March 2015 Accepted 19 March 2015 Available online 20 March 2015 Keywords: Atrial fibrillation Non-pulmonary focus Persistent left superior vena cava

A 59-year-old highly symptomatic male patient with drug-resistant paroxysmal atrial fibrillation (AF) was referred to our arrhythmia center for AF ablation. During his initial clinical evaluation transthoracic echocardiography showed a giant coronary sinus and suggested a persistent left superior vena cava (PLSVC) with saline infusion via the left antecubital vein. Further analysis with cardiac computed tomography angiography with 3-D reconstruction clearly demonstrated the giant coronary sinus and the PLSVC, which normally becomes the ligament of Marshall located between the left atrial appendage and left pulmonary veins (Figs. 1 and 2). Initial electrophysiologic evaluation suggested a non-pulmonary focus triggering short episodes of AF. Fast anatomical mapping using Carto-3 system including the left atrium, pulmonary veins, the PLSVC, and the coronary sinus demonstrated similar anatomical relationships seen in computed tomography (Figs. 3 and 4). The earliest local activation initiated regularly and then triggering the episodes resulted in an irregular activation (Fig. 5) was seen on the

⁎ Corresponding author. E-mail address: [email protected] (S. Cay). 1 The first two authors contributed equally to this work.

http://dx.doi.org/10.1016/j.ijcard.2015.03.309 0167-5273/© 2015 Elsevier Ireland Ltd. All rights reserved.

Lasso catheter located at the floor of the proximal PLSVC neighboring the left atrial ridge (Fig. 6). The activation sequence of a far-field atrial potential preceding the PLSVC potential during sinus rhythm reversed during focal ectopic activity (Figs. 7 and 5). Pacing from the left atrial appendage clearly differentiated the local potential in the PLSVC and the far-field atrial potential (Fig. 8). Two-stage ablation procedure was performed; initial circumferential ablation (25 W, 43 °C and 17 mL/min) at the junction between the PLSVC and the distal end of the coronary sinus (Fig. 9) then pulmonary vein isolation with wide area circumferential ablation (Fig. 10). After circumferential ablation of the PLSVC no local potentials (Fig. 11) were seen and high output pacing approved the electrical isolation (Fig. 12). There was no procedure-related complication. An uneventful 12-month follow-up without anti-arrhythmic therapy was reported. Non-pulmonary foci have important role as potential triggers of AF [1] and these foci can also be located in congenitally anomalous veins such as the PLSVC as in our case. Ablation and electrical isolation of the PLSVC in addition to pulmonary veins should be the end-point of AF ablation. Conflict of interest None. Reference [1] M. Takigawa, T. Kuwahara, A. Takahashi, et al., Differences in catheter ablation of paroxysmal atrial fibrillation between males and females, Int. J. Cardiol. 168 (2013) 1984–1991.

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Fig. 1. 3-D computed tomography showed close proximity of the PLSVC to the left atrial ridge, LAA and left pulmonary veins on anterior (1) and posterior (2) aspects. Same anatomical relationships were seen as 3-D mapping with Carto-3 system on the left (3) and right (4) anterior oblique projections. Intracardiac electrograms demonstrated a regular early local potential preceding a far-field atrial potential subsequently resulted in an irregular activation suggesting AF (5) on the Lasso catheter (6). Activation sequence of both potentials reversed during sinus rhythm (7) and they can be visualized more clearly with pacing (8). Ablation points (red dots) at the level of the junction between the PLSVC and the CS (9) and around pulmonary veins (10) were seen on the right anterior oblique projection. No local potentials (11) and electrical isolation (12) were achieved at the end of the procedure. ABL, ablation catheter; AF, atrial fibrillation; CS, coronary sinus; His, His catheter; LA, left atrium; LAA, left atrial appendage; LIPV, left inferior pulmonary vein; LSPV, left superior pulmonary vein; PLSVC, persistent left superior vena cava; RIPV, right inferior pulmonary vein; RSPV, right superior pulmonary vein. (For interpretation of the references to color in this figure legend, the reader is referred to the web version of this article.)

A rare localization for non-pulmonary vein trigger of atrial fibrillation: persistent left superior vena cava.

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