Case Reports: Radiofrequency Catheter Ablation of Typical Atrial Flutter and the Atrioventricular Junction via the Superior Vena Caval Approach in a Patient with a Congenital Absence of an Inferior Vena Cava

Catheter ablation of typical atrial flutter with the superior approach in a patient with inferior vena cava interruption

Inferior vena cava (IVC) interruption is a rare condition that might pose difficulties during typical flutter ablation. When azygos vein continuation is present ablation via the femoral route could be performed. In the absence of azygos vein continuation, typical atrial flutter ablation via a superior approach from the SVC is feasible.

Atrial flutter in a patient with atrial septal defect and anomalous venous drainage : unusual approach for ablation

Atrial flutter ablation in CHD (Congenital Heart Disease) patients is a challenging procedure because of the possibility of multiple circuits. Electroanatomical mapping and pacing maneuvers are crucial to determine critical isthmus. Moreover, vascular abnormalities and residual cardiac defects need to be known before the ablation to decide the better strategy for ablation.

Catheter ablation of atrial arrhythmias in a patient with surgically corrected congenital heart disease and inferior vena cava interruption

A 15 year old girl who underwent surgical correction of ventricular septal defect and patent ductus arteriosus ligation in childhood presented with atrial tachycardia of crista terminalis origin and counterclockwise atrial flutter. She also had associated interruption of inferior vena cava which continued as azygous vein and left superior vena cava which drained via coronary sinus into the right atrium. She underwent radiofrequency ablation of both the tachycardias via internal jugular vein and azygous vein approach using 3D electroanatomical mapping system.

Systemic venous anatomy in congenital heart disease: implications for electrophysiologic testing and catheter ablation

INTRODUCTION

Cardiac arrhythmias are a significant problem in patients with congenital heart disease. Many patients with congenital heart disease have abnormal systemic venous anatomy which can complicate electrophysiologic testing, catheter ablation and pacemaker and defibrillator implantation. We reviewed the systemic venous anatomy in a cohort of patients undergoing electrophysiologic testing and catheter ablation.

METHODS AND RESULTS

We reviewed all electrophysiologic studies performed in patients with adult congenital heart disease (n = 80) at our institution between January 1998 and October 2009. Ten patients (13%) had a congenital systemic venous anomaly. Of these, seven (9%) had a left superior vena cava and four (5%) had infrahepatic interruption of the inferior vena cava (two had both anomalies). One patient's inferior vena cava was connected to a left-sided atrium; she had right atrial isomerism. In four patients (40%), systemic venous abnormalities were discovered at the time of electrophysiologic testing.

CONCLUSIONS

Systemic venous anomalies occur frequently in the congenital heart disease population and may complicate electrophysiologic testing and catheter ablation. Pre-procedural imaging may assist in facilitating a successful procedure.

Noncontact mapping guided ablation of right ventricular outflow tract ectopy in a patient with interruption of the inferior vena cava and azygos continuation

A 58-year-old woman with symptomatic multiple monomorphic premature ventricular beats of a right ventricular outflow tract origin was referred for ablation. An inferior vena cava interruption with azygos continuation was discovered during catheter placement. This case describes positioning of the noncontact mapping array and successful radiofrequency ablation in this challenging anatomy.

Hepatico-tricuspid isthmus ablation for typical-like atrial flutter by femoral approach in absence of the inferior vena cava: use of magnetic navigation and three-dimensional mapping with image integration

The previously unknown congenital absence of inferior vena cava, an otherwise benign condition, may create difficulties for catheter ablation of arrhythmias. We describe a case of a typical-like atrial flutter, in which magnetic navigation was important for conserving the femoral approach. Electroanatomic mapping with image integration helped define the critical isthmus between the ostia of the suprahepatic veins and the tricuspid valve.

Remote navigation guided ablation of incessant atrial tachycardia in a patient with restricted venous access

We report a case of a 45-year-old man with incessant supraventricular tachycardia (SVT) in the setting of intrahepatic inferior vena cava thrombus and a left upper extremity arteriovenous fistula. A diagnostic electrophysiology study (EPS) was performed via the right internal jugular and right subclavian veins. After confirming the mechanism of SVT was atrial tachycardia (AT), mapping, and successful ablation was performed using remote catheter navigation. This case demonstrates that remote navigation can facilitate the therapy of complex arrhythmias in challenging clinical situations.

Radiofrequency catheter ablation of the slow pathway for atrioventricular nodal reentry in a patient with an obstructed inferior vena cava

A 51-year-old man with an obstructed inferior vena cava underwent successful slow pathway catheter ablation using a superior venous approach. Two central venous sheaths were introduced into the right internal jugular vein using different approaches (anterior and posterior), so the two sheaths located away from each other could prevent the catheters from 'sticking' to one another. The transseptal long sheath enabled a stable positioning of the ablation catheter. A nonfluoroscopic mapping system could reduce radiation exposure to the ablator. These techniques may be useful to overcome the disadvantages of the superior venous approach compared to the inferior venous approach.