Trans-aortic pulmonary vein isolation using magnetic navigation system for paroxysmal atrial fibrillation in a patient with dextrocardia, situs inversus, and inferior vena cava continuity with azygos vein

Trans-aortic mitral isthmus ablation after surgical patch closure for an atrial septal defect

INTRODUCTION

In patients with prior atrial septal defect (ASD) closure and atrial tachyarrhythmias, transseptal puncture can be challenging.

METHODS AND RESULTS

This case report discusses a 65-year-old man who had previously undergone pulmonary vein isolation (PVI) and cavo-tricuspid isthmus ablation for atrial fibrillation before ASD closure, respectively. He developed atrial tachycardia (AT) and underwent catheter ablation. AT was diagnosed as peri-mitral flutter and the mitral isthmus (MI) linear ablation via a trans-aortic approach successfully terminated it.

CONCLUSION

This case demonstrates the feasibility and safety of transaortic MI linear ablation in patients with ASD closure devices or anatomical challenges when transseptal puncture is difficult.

Radiofrequency ablation of persistent atrial fibrillation in a patient with situs inversus totalis and interrupted inferior vena cava

INTRODUCTION

Catheter ablation of atrial fibrillation (AF) has emerged as the most effective therapy. However, rare anatomical abnormalities such as situs inversus totalis, dextrocardia, or interrupted inferior vena cava can make ablation challenging.

METHODS AND RESULTS

We report a case of a 55-year-old woman with situs inversus totalis, dextrocardia, surgical atrial septal defect repair, left-sided dual chamber pacemaker in place, and symptomatic recurrent persistent AF who underwent successful pulmonary vein and posterior wall isolation by the superior access from the left internal jugular vein.

CONCLUSIONS

It is a feasible and safe approach with support of transesophageal echocardiography and multiple emerging technologies.

Thoracoscopic AF ablation in situs inversus dextrocardia with interrupted inferior vena cava continuation in azygos vein

Introduction

Situs inversus totalis, dextrocardia with interrupted inferior vena cava, and azygos vein continuation concomitant with symptomatic atrial fibrillation requiring ablation. This case was deemed not suitable for percutaneous ablation due to anatomic variations and the lack of case reports in the literature.

Methods and Results

We performed bilateral thoracoscopic epicardial ablation and epicardial left atrial appendage exclusion. The direct vision allowed for a complete box lesion set with bipolar radiofrequency device. Patient remained in sinus rhythm at the 12‐months follow‐up.

Conclusion

Surgical thoracoscopic epicardial ablation is safe and effective also in congenital defects. Multidisciplinary expertise can offer minimally invasive ablation treatments.

Radiofrequency ablation for paroxysmal atrial fibrillation in a patient with dextrocardia and interruption of the inferior vena cava: a case report

Background

Dextrocardia with interruption of the inferior vena cava (I-IVC) is a very rare anatomical variant. Catheter ablation of atrial fibrillation (AF) in patients with this anatomical variant is challenging for electrophysiologists. This case report presents a safe, effective, and radiation-free approach for high-power ablation of AF via a superior transseptal approach in patients with dextrocardia and I-IVC.

Case summary

A 57-year-old man with paroxysmal AF with dextrocardia and I-IVC with azygos continuation was referred to our hospital for radiofrequency (RF) ablation. It was evident that transseptal puncture and pulmonary vein isolation (PVI) would be impossible using an IVC approach via the femoral vein. Therefore, we decided to perform left atrium (LA) ablation via the superior vena cava approach. A phased array intracardiac echocardiography (ICE) catheter was inserted in the right femoral vein. Three-dimensional (3D) anatomical reconstruction of LA, right atrium (RA), and coronary sinus (CS) ostium were performed using ICE with azygos vein and RA imaging. Navigation-enabled electrodes were inserted into annotated CS on cardiac 3D ICE image. The left internal jugular vein was accessed using an SL1 transseptal sheath and Brockenbrough needle. Transseptal puncture was performed under ICE with an RF-assisted approach. We accomplished ablation index guided high-power pulmonary vein isolation using a bi-directional guiding sheath with visualization capabilities and a surround flow contact force-sensing catheter. No complications occurred during or after the procedure.

Discussion

With the application of multitude of newer technologies, we can accomplish safe, effective, and fluoroscopy-free RF ablation of AF using the superior approach in patients with complex anomaly.

Successful Catheter Ablation for Multiple Atrial Arrhythmias in a Patient with Situs Inversus Totalis

A 70-year-old woman with situs inversus totalis underwent catheter ablation for atrial fibrillation and atrial flutter. Although her morphologic left atrium (LA) was enlarged, we performed cryoballoon ablation and liner radiofrequency ablation of the cava-tricuspid isthmus without mapping atrial arrhythmias. However, a different form of atrial tachycardia (AT) recurred. We performed catheter ablation a second time using a three-dimensional electroanatomic mapping system. AT was not terminated by the liner ablation at the roof of morphologic LA and mitral isthmus but sustained by changing the atrial activation sequence and cycle length. Multipolar mapping catheter revealed that fractionated low-amplitude potentials were densely located in a limited area of the anterior morphologic LA, and an activation map demonstrated the presence of small-circuit reentry with an extremely slow conduction at the anterior morphologic LA. A single energy application targeting the fragmented potentials successfully terminated the AT. We successfully treated multiple ATs with a complex anatomy using a three-dimensional electroanatomic mapping system.

Catheter ablation of atrial fibrillation in situs inversus dextrocardia: Challenge, improved procedure, outcomes, and literature review

INTRODUCTION

Catheter ablation for atrial fibrillation (AF-CA) in patients with situs inversus dextrocardia (SID) can be challenging because of the contrary anatomy and associated anomalies. Cases and literature regarding AF-CA in SID are rare and provide little information. Our study aims to present an improved procedure, ablation strategies, and evaluate the safety and outcomes of AF-CA in patients with AF and SID.

METHODS

A total of 10 patients with AF-SID (mean age, 60.4 ± 15.7 years; six paroxysmal AF, four persistent atrial fibrillation [PeAF]) were enrolled. For the improved procedure, images obtained by preacquired computed tomography and three-dimensional electroanatomical mapping, integrating intracardiac echocardiography, and x-ray imaging data are necessary to optimize the transseptal puncture and ablation procedure.

RESULTS

All patients successfully underwent 13 AF-CA procedures without complications, including three patients received repeat procedures. However, two PeAF patients presented sick sinus syndrome (SSS) after the AF-CA procedure, and one underwent permanent pacemaker implantation therapy during hospitalization. During the follow-up period (6-72 months), the outcomes were not favorable: three patients (30%) maintained sinus rhythm (SR) after the initial procedure; after repeated procedures, the overall SR rate was 40% (four patients).

CONCLUSION

With the improved strategy, AF-CA can be safely and effectively performed with low radiation exposure in patients with SID. However, the long-term outcomes were not favorable, even when managed at a tertiary center by a team of specialists. Moreover, patients with PeAF might also have masked SSS, which should be carefully considered.