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Successful Cavotricuspid Isthmus Ablation in a Patient with an Interrupted Inferior Vena Cava and Persistent Left Superior Vena Cava TAKUMI YAMADA, M.D.,∗ YUNG R. LAU, M.D.,† and G. NEAL KAY, M.D.∗ From the ∗ Division of Cardiovascular Disease; and †Department of Pediatric Cardiology, University of Alabama at Birmingham, Birmingham, Alabama, USA
atrial flutter, azygos vein, interrupted inferior vena cava, persistent left superior vena cava, radiofrequency catheter ablation A 46-year-old man with atrial flutter (AFL) underwent electrophysiologic testing. He had a history of a heterotaxy syndrome with a persistent left superior vena cava (PLSVC) that was draining via the coronary sinus (CS) into the morphologic right atrium, infrahepatic interruption in the inferior vena cava (IVC) with an azygous/hemiazygous continuation that was draining into the PLSVC, and surgical repair of a ventricular septal defect. At baseline, a typical AFL persisted (Fig. 1). A decapolar catheter was positioned at the J Cardiovasc Electrophysiol, Vol. 26, pp. 450-451, April 2015. No disclosures. Address for correspondence: Takumi Yamada, M.D., Ph.D., Division of Cardiovascular Disease, University of Alabama at Birmingham, FOT 930A, 510 20th Street South, 1530 3rd Ave S, Birmingham, AL 35294-0019, USA. Fax: +1-205-996-5857; E-mail: [email protected] doi: 10.1111/jce.12588
cavotricuspid isthmus (CTI) via a femoral approach through the azygos vein, PLSVC and CS (Fig. 1). The atrial activation sequences at the CTI were from lateral to septal, and entrainment pacing at the CTI revealed that the post pacing interval equaled to the cycle length of the AFL. Based on these findings, the AFL was diagnosed as counter-clockwise CTI-dependent AFL. An 8 mm-tip ablation catheter was then positioned at the CTI via the same femoral approach as the decapolar catheter (Fig. 1). A linear radiofrequency ablation was performed at the CTI, resulting in termination of the AFL. Following this, atrial pacing performed from the distal electrode pair of the ablation catheter that was positioned on the lateral side of the ablation line confirmed CTI conduction block by revealing that the atrial activation sequences were septal to lateral on the septal side of the ablation line (Fig. 2). During a follow-up period of more than 6 months, the patient has been free from any AFL recurrences without any antiarrhythmic drugs. No complications occurred.
Yamada et al.
CTI ABL through the Persistent Left SVC
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Figure 1. Left panel: Twelve-lead ECG exhibiting the atrial flutter. Right upper panel: Fluoroscopic image exhibiting a coronary sinus (CS) venogram and right atriogram and ventriculogram obtained by a contrast injection through the persistent left superior vena cava. Right lower panel: Fluoroscopic image exhibiting the CS catheter and ablation catheter that were positioned through the persistent left superior vena cava. Note that the ablation catheter was positioned at the cavotricuspid isthmus. ABL = ablation catheter; PA = pulmonary artery; RA = right atrium; RAO = right anterior oblique view; RV = right ventricle.
Figure 2. Left panel: Cardiac tracings exhibiting conduction block at the cavotricuspid isthmus. Note that pacing was performed from the distal electrode pair of the ablation catheter, which was positioned on the lateral side of the ablation line at the cavotricuspid isthmus. Also note that the proximal electrode pair of the ablation catheter was positioned on the septal side of the ablation line. Right upper panel: Fluoroscopic image exhibiting a coronary sinus (CS) venogram and right atriogram obtained by a contrast injection through the persistent left superior vena cava. Right lower panel: Fluoroscopic image exhibiting the catheter positions when the pacing study was performed to confirm conduction block at the cavotricuspid isthmus. ABLd(p) = distal and proximal electrode pairs of the ablation catheter; CS 1 to 5 = first to fifth electrode pairs of the CS catheter; LAO = left anterior oblique view. The other abbreviations are as in Figure 1.
This document is a scanned copy of a printed document. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material.
EP Image
Successful Cavotricuspid Isthmus Ablation in a Patient with an Interrupted Inferior Vena Cava and Persistent Left Superior Vena Cava TAKUMI YAMADA, M.D.,∗ YUNG R. LAU, M.D.,† and G. NEAL KAY, M.D.∗ From the ∗ Division of Cardiovascular Disease; and †Department of Pediatric Cardiology, University of Alabama at Birmingham, Birmingham, Alabama, USA
atrial flutter, azygos vein, interrupted inferior vena cava, persistent left superior vena cava, radiofrequency catheter ablation A 46-year-old man with atrial flutter (AFL) underwent electrophysiologic testing. He had a history of a heterotaxy syndrome with a persistent left superior vena cava (PLSVC) that was draining via the coronary sinus (CS) into the morphologic right atrium, infrahepatic interruption in the inferior vena cava (IVC) with an azygous/hemiazygous continuation that was draining into the PLSVC, and surgical repair of a ventricular septal defect. At baseline, a typical AFL persisted (Fig. 1). A decapolar catheter was positioned at the J Cardiovasc Electrophysiol, Vol. 26, pp. 450-451, April 2015. No disclosures. Address for correspondence: Takumi Yamada, M.D., Ph.D., Division of Cardiovascular Disease, University of Alabama at Birmingham, FOT 930A, 510 20th Street South, 1530 3rd Ave S, Birmingham, AL 35294-0019, USA. Fax: +1-205-996-5857; E-mail: [email protected] doi: 10.1111/jce.12588
cavotricuspid isthmus (CTI) via a femoral approach through the azygos vein, PLSVC and CS (Fig. 1). The atrial activation sequences at the CTI were from lateral to septal, and entrainment pacing at the CTI revealed that the post pacing interval equaled to the cycle length of the AFL. Based on these findings, the AFL was diagnosed as counter-clockwise CTI-dependent AFL. An 8 mm-tip ablation catheter was then positioned at the CTI via the same femoral approach as the decapolar catheter (Fig. 1). A linear radiofrequency ablation was performed at the CTI, resulting in termination of the AFL. Following this, atrial pacing performed from the distal electrode pair of the ablation catheter that was positioned on the lateral side of the ablation line confirmed CTI conduction block by revealing that the atrial activation sequences were septal to lateral on the septal side of the ablation line (Fig. 2). During a follow-up period of more than 6 months, the patient has been free from any AFL recurrences without any antiarrhythmic drugs. No complications occurred.
Yamada et al.
CTI ABL through the Persistent Left SVC
451
Figure 1. Left panel: Twelve-lead ECG exhibiting the atrial flutter. Right upper panel: Fluoroscopic image exhibiting a coronary sinus (CS) venogram and right atriogram and ventriculogram obtained by a contrast injection through the persistent left superior vena cava. Right lower panel: Fluoroscopic image exhibiting the CS catheter and ablation catheter that were positioned through the persistent left superior vena cava. Note that the ablation catheter was positioned at the cavotricuspid isthmus. ABL = ablation catheter; PA = pulmonary artery; RA = right atrium; RAO = right anterior oblique view; RV = right ventricle.
Figure 2. Left panel: Cardiac tracings exhibiting conduction block at the cavotricuspid isthmus. Note that pacing was performed from the distal electrode pair of the ablation catheter, which was positioned on the lateral side of the ablation line at the cavotricuspid isthmus. Also note that the proximal electrode pair of the ablation catheter was positioned on the septal side of the ablation line. Right upper panel: Fluoroscopic image exhibiting a coronary sinus (CS) venogram and right atriogram obtained by a contrast injection through the persistent left superior vena cava. Right lower panel: Fluoroscopic image exhibiting the catheter positions when the pacing study was performed to confirm conduction block at the cavotricuspid isthmus. ABLd(p) = distal and proximal electrode pairs of the ablation catheter; CS 1 to 5 = first to fifth electrode pairs of the CS catheter; LAO = left anterior oblique view. The other abbreviations are as in Figure 1.
This document is a scanned copy of a printed document. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material.
