Original-clinicalAtrial fibrillationCatheter ablation of atrial fibrillation via superior approach in patients with interruption of the inferior vena cava
Introduction
Catheter ablation has been established as a curative treatment strategy for atrial fibrillation (AF) and its use has increased exponentially in the clinical field.1 The standard procedure is performed via the right or left femoral vein, and all devices are designed to be delivered via the femoral venous approach. However, in patients with anatomical obstruction of the inferior vena cava (IVC), i.e., IVC interruption or variant anatomy, an alternative technique and vascular access are required.
It has been reported that transjugular vein access for percutaneous closure of septal defects is feasible when the IVC is obstructed or interrupted.2, 3 However, catheter ablation of AF in patients with IVC interruption has not been reported.
The primary objective of this study was to show the safety and feasibility of the superior transjugular approach in performing a transseptal puncture and then ablation inside the left atrium (LA) including electrical isolation of the pulmonary veins (PVs).
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Methods
Catheter ablation via the superior approach was performed in 3 male patients with drug-refractory AF and complete interruption of the IVC (mean age: 51.7 ± 18.5 years). All antiarrhythmic drugs were discontinued for at least 5 half-lives, and written informed content was obtained before the procedure. Transesophageal echocardiography (TOE) was performed to exclude thrombi in the LA in all patients, and multidetected computed tomographic (MDCT) scanning was performed for image integration into
Case 1
A 33-year-old man with a 2-year history of drug-refractory paroxysmal AF was referred to our hospital because vascular access for catheter ablation failed due to complete interruption of the IVC. Venography revealed complete interruption of the IVC with venous drainage of the lower body into the hemiazygous vein at the level of the renal vein (Figure 2A). A-F decapolar catheter (St. Jude Medical, Inc.) was positioned in the CS via the left subclavian vein and the duodecapolar catheter was
Discussion
Transseptal puncture is a crucial procedure for accessing the LA for catheter-based treatment, and is dependent on the individual physician's skill and experience. However, it might present technical difficulties in patients who have concomitant cardiac or extracardiac deformities, and might be inaccessible via the femoral veins in cases of anatomic variants or obstacles in the IVC.
Congenital obstruction of the IVC is uncommon and may present as an incomplete membrane or as complete
Conclusion
We first demonstrated the safety and feasibility of AF ablation via the superior approach in patients with complete interruption of the IVC.
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