Atrial Transseptal Catheterisation: Challenging Scenarios and Techniques to Overcome Them

Atrial transseptal catheterisation is a fundamental skill of any interventional electrophysiologist. In this review, various scenarios that pose unique challenges to atrial transseptal catheterisation are discussed. These scenarios include post-surgical or congenital malformations of the interatrial septum, presence of interatrial septal closure devices, absent or obstructed inferior vena cava and complex congenital heart disease after palliative surgery. Transseptal catheterisation in all of the above situations is feasible and can be performed safely with the aid of dedicated tools and specific techniques.

The supernumerary valve in the right atrium of the human heart: A rare case of "the valve of superior caval vein"

The valve of superior caval vein (SCV) is seldom detected and reported. With the increasing popularity of cardiac interventional procedures, it should be paid more attention rather than ignored in clinical practice. Here, we presented a case of the SCV valve detected by transthoracic echocardiography, which was first shown as a valvular structure at the top of the right atrium and ultimately found to be located at the orifice of SCV. And the identification of the valve of SCV will undoubtedly be helpful for risk aversion in future cardiac interventional procedures.

Systematic review of electrophysiology procedures in patients with obstruction of the inferior vena cava

AIMS

The objective of the study was to conduct a systematic review to describe and compare the different approaches for performing cardiac electrophysiology (EP) procedures in patients with interrupted inferior vena cava (IVC) or equivalent entities causing IVC obstruction.

METHODS

We conducted a structured search to identify manuscripts reporting EP procedures with interrupted IVC or IVC obstruction of any aetiology published up until August 2020. No restrictions were applied in the search strategy. We also included seven local cases that met inclusion criteria.

RESULTS

The analysis included 142 patients (mean age 48.9 years; 48% female) undergoing 143 procedures. Obstruction of the IVC was not known before the index procedure in 54% of patients. Congenital interruption of IVC was the most frequent cause (80%); and, associated congenital heart disease (CHD) was observed in 43% of patients in this setting. The superior approach for ablation was the most frequently used strategy (52%), followed by inferior approach via the azygos or hemiazygos vein (24%), transhepatic approach (14%), and retroaortic approach (10%). Electroanatomical mapping (58%), use of long sheaths (41%), intracardiac echocardiography (19%), transesophageal echocardiography (15%) and remote controlled magnetic navigation (13%) were used as adjuncts to aid performance. Ablation was successful in 135 of 140 procedures in which outcomes were reported. Major complications were only reported in patients undergoing AF ablation, including two patients with pericardial effusion, one of whom required surgical repair, and another patient who died after inadvertent entry into an undiagnosed atrioesophageal fistula from a previous procedure.

CONCLUSION

The superior approach is most frequent approach for performing EP procedures in the setting of obstructed IVC. Transhepatic approach is a feasible alternative, and may provide a "familiar approach" for transseptal access when it is required. Adjunctive use of long sheaths, intravascular echocardiography, electro-anatomical mapping and remote magnetic navigation may be helpful, especially if there is associated complex CHD. With careful planning, EP procedures can usually be successfully performed with a low risk of complications.

Remote magnetic navigation ablation via the right jugular vein approach in patient with interruption of the inferior vena cava and incessant left atrial flutter

Remote magnetic navigation (RMN) can be safely and effectively utilized in patients with difficult cardiac arrhythmias and complex anatomy. Interruption of the inferior vena cava (IVC) is a rare congenital abnormality that results in the inability to use conventional femoral access in patients that require interventional procedures. The present case demonstrates the feasibility of left atrial flutter ablation using RMN via jugular approach in a patient with interruption of IVC.

Radiofrequency-Assisted Transseptal Access for Atrial Fibrillation Ablation Via a Superior Approach

OBJECTIVES

This study describes the technique and outcomes of atrial fibrillation (AF) ablation via a superior approach in patients with interrupted or absent inferior vena cavas (IVCs).

BACKGROUND

In patients with interrupted or absent IVCs, transseptal access cannot be obtained via standard femoral venous access. In these patients, alternative strategies are necessary to permit catheter ablation in the left atrium (LA). This study reports on the outcomes of AF ablation from a superior venous access with a radiofrequency (RF)-assisted transseptal puncture (TSP) technique.

METHODS

This study identified patients with interrupted or absent IVCs who underwent AF ablation via a superior approach at 2 ablation centers from 2010 to 2019.

RESULTS

Fifteen patients (mean age: 50.8 ± 11.2 years; 10 men; 10 with paroxysmal AF) with interrupted or absent IVCs underwent AF ablation with transseptal access via a superior approach. Successful TSP was performed either with a manually bent RF transseptal needle (early cases: n = 4) or using a RF wire (late cases: n = 11); this approach permitted LA mapping and ablation in all patients. Mean time required to perform single (n = 8) or double (n = 7) TSP was 16.1 ± 4.8 min, and mean total procedure time was 227.9 ± 120.7 min (fluoroscopy time: 57.0 ± 28.5 min). LA mapping and ablation were successfully performed in all patients.

CONCLUSIONS

In patients with AF undergoing catheter ablation and who had a standard transseptal approach via femoral venous approach is impossible due to anatomic constraints, RF-assisted transseptal access via a superior approach can be an effective alternative strategy to permit LA mapping and ablation.

Management of patients with interrupted inferior vena cava requiring electrophysiology procedures

BACKGROUND

Interrupted inferior vena cava (IVC) is a rare venous anomaly that complicates the treatment of patients who require electrophysiology (EP) procedures.

METHODS

We describe five consecutive cases of patients with interrupted IVC who presented to the EP laboratory requiring interventional procedures including catheter ablation for atrial fibrillation and supraventricular tachycardia and left atrial appendage closure. All cases were successfully completed utilizing a variety of approaches to vascular access including transseptal puncture via transhepatic and internal jugular approaches.

CONCLUSION

Procedures in the EP lab can be performed successfully in patients with interrupted IVC.

How to perform left atrial transseptal access and catheter ablation of atrial fibrillation from a superior approach

The standard technique for percutaneous catheter ablation of atrial fibrillation (AF) involves obtaining left atrial access and catheter manipulation from an inferior transfemoral venous access. However, in patients with inferior vena cava interruption, a standard transfemoral venous approach is not possible. In these cases, a percutaneous approach from a superior central vein, such as the internal jugular vein or the axillary/subclavian vein can be considered. In this article, we describe the details of our technique to obtain left atrial catheterization and perform catheter ablation of AF from a superior approach. Our technique involves the use of steerable sheaths, dedicated radiofrequency wires, and intracardiac echocardiography guidance.

Transseptal puncture and catheter ablation via the superior vena cava approach for persistent atrial fibrillation in a patient with polysplenia syndrome and interruption of the inferior vena cava: contact force-guided pulmonary vein isolation

Aims

We sought to establish the technical feasibility of transseptal puncture and left atrial (LA) ablation through the right internal jugular vein via the superior vena cava (SVC) approach in patients with an interrupted inferior vena cava (IVC).

Methods and results

A 34-year-old man with persistent atrial fibrillation (AF) and polysplenia syndrome (hypoplasia of the left kidney, aplasia of the pancreas tail, bilaterally bilobed lungs, and an interrupted IVC) was referred to our hospital for radiofrequency ablation. Because transseptal puncture and LA ablation would be impossible by a standard IVC approach via the femoral vein, we performed transseptal puncture and LA ablation through the right internal jugular vein via the SVC approach using a manually curved Brockenbrough needle and intracardiac echocardiographic guidance. We accomplished pulmonary vein (PV) isolation using a deflectable guiding sheath and a contact force-sensing ablation catheter to monitor the contact force and the force-time integral of the tip of the ablation catheter. No complications occurred during or after the procedure. The patient was discharged home without recurrence of AF 3 days after the procedure. He had no recurrence of AF and was taking no medication 5 months after ablation.

Conclusions

We successfully performed transseptal puncture in a patient with persistent AF, polysplenia syndrome, and complete interruption of the IVC using the superior route through the internal jugular vein. We also accomplished PV isolation using a deflectable guiding sheath and real-time monitoring of the contact force of the ablation catheter.

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.

Atrial tachycardia originating from the hepatic segment of inferior vena cava in interruption of inferior vena cava with azygos continuation

Interruption of inferior vena cava (IVC) with azygos continuation is a rare venous anomaly, and arrhythmogenic IVC is also rarely reported. Arrhythmogenicity of the hepatic segment of IVC in interruption of IVC has never been reported. We describe the case of a 37-year-old female with interrupted left IVC with azygos continuation to right superior vena cava and atrial tachycardia originating from the hepatic segment of IVC.