Elsevier

Heart Rhythm

Volume 6, Issue 2, February 2009, Pages 174-179
Heart Rhythm

Original-clinical
Atrial fibrillation
Catheter ablation of atrial fibrillation via superior approach in patients with interruption of the inferior vena cava

https://doi.org/10.1016/j.hrthm.2008.10.026Get rights and content

Background

Percutaneous transcatheter ablation of atrial fibrillation (AF) in patients with interruption of inferior vena cava (IVC) has not been reported in the literature.

Objective

The purpose of this article was to demonstrate the safety and feasibility of the superior approach via the right internal jugular vein in performing catheter ablation of AF.

Methods

We performed AF ablation in 3 patients (mean age: 51.7 ± 18.5 years, 2 paroxysmal AF and 1 persistent AF) with complete interruption of IVC. Transseptal puncture was performed via the right internal jugular vein with a long sheath and manually curved Brockenbrough needle to facilitate the tip downward to the FO. Three-dimensional (3D) mapping was performed in 2 patients. Electrical isolation of each pulmonary vein (PV) was confirmed by a circular mapping catheter. Bidirectional block at the RA isthmus was achieved in 1 patient with clinically documented typical atrial flutter.

Results

In all patients, AF ablation after transseptal puncture via the superior approach was successfully performed without complications. Selective PV isolation of arrhythmogenic PV was done in 1 patient, and circumferential bilateral antral ablations were done in 2 patients. In 1 patient with persistent AF, linear ablations of left atrial roof and perimitral and RA isthmus were done after electrical isolation of all PVs. At a mean follow-up of 18.7 ± 15.5 months, arrhythmias were free without any antiarrhythmic drugs in all patients.

Conclusion

AF ablation via the superior approach is a safe and feasible alternative technique when a femoral venous approach is not available.

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).

Section snippets

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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