Impact of persistent left superior vena cava on radiofrequency catheter ablation in patients with atrial fibrillation

Technical Report of Radiofrequency Ablation of AVNRT with Persistent Left Superior Vena Cava: Success Relies on Basics

Background/Objectives: Persistent Left Superior Vena Cava (PLSVC) is a condition that may complicate the ablation of Atrioventricular nodal reentry tachycardia (AVNRT). We aimed to report technical experience in ablation under scuh clinical setting. Methods: 3D guided electrophysiological procedure was conducted and PLSVC was confirmed. Slow-pathway ablation for the AVNRT was performed and typical junctional rhythm during the ablation was observed. Results: Exactly the same AVNRT remained inducible after 10 radiofrequency applications, which was very likely because of suboptimal temperature increase due to lacking sustained stability/contact of the catheter given the PLSVC anatomy and the patient's deep respiration based on our observation during the RF applications. A non-steerable long sheath was introduced to achieve more firm contact of the ablation catheter, the slow-pathway was successfully ablated with just 1 application (seen immediately occurred, continuous typical junctional rhythms during ablation, and significantly better temperature during the ablation). Conclusions: PLSVC-related anatomical changes may destabilize ablation catheter making it difficult to establish sufficient energy delivery at the slow-pathway region and put forward the need for multiple ablations. Timely identifying such scenarios (e.g., insufficient stability, insufficient temperature) could help better plan/change the ablation technique or strategy to achieve better procedure outcomes. This technical report reminds us that typical junctional beats may not be the only determinant for successful ablation of the slow-pathway. The key to the solution often relies on basic ablation biophysics.

Coronary sinus thrombosis: insights from a comprehensive literature review

Coronary sinus thrombosis (CST) is a rare and severe disease that remains underrecognized in clinical practice. Most documented cases fall within the acute category, with non-specific symptoms, rapid progression, and a high mortality rate. In contrast, some cases follow an insidious course, leading to the formation of partial or incomplete thrombi that may not cause immediate death but can progress to severe complications over time. This review study the pathophysiology, clinical presentations, diagnostic challenges, and the association with persistent left superior vena cava (PLSVC), emphasizing the utility of imaging modalities such as Echocardiography, Computed Tomography, Magnetic Resonance Imaging and Venography. For management, anticoagulation remains the cornerstone of treatment for CST, with surgical thrombectomy reserved for severe or refractory cases. Post-treatment follow-up is highlighted as essential for monitoring recurrence and managing complications. In brief, the aim of this review is to enhance the understanding of CST and improve clinical outcomes through early recognition, tailored interventions, and multidisciplinary care.

Techniques and outcomes of atrial fibrillation ablation in patients with persistent left superior vena cava

OBJECTIVES

To investigate tailored approaches, techniques, and outcomes of catheter ablation in patients with persistent left superior vena cava (PLSVC) undergoing atrial fibrillation (AF) ablation.

BACKGROUND

PLSVC presents unique challenges for AF ablation due to its potential as an arrhythmogenic source and the complex anatomical variations it introduces.

METHODS

The retrospective cohort included 16 patients with PLSVC that underwent 21 AF ablation procedures between August 1, 2008, and February 14, 2024, at the Hospital of the University of Pennsylvania. Procedures involved pre-ablation imaging, 3D electroanatomical mapping, pulmonary vein isolation, and targeted ablation strategies focusing on the PLSVC-related ablation. The primary endpoints were procedural safety and AF recurrence postablation.

RESULTS

The cohort's mean age was 51.9 ± 17.9 years, 31.2% of whom were female. Triggers from the PLSVC were identified in 66.7% of procedures. Tailored ablation strategies were employed to isolate PLSVC-left atrium/coronary sinus connections or directly target the induced triggers, with a success rate of 85% in achieving isolation or targeted ablation once triggers were induced. The recurrence rate of arrhythmia postablation was 46.7% in the patient-based analysis and 65% in the procedure-based analysis. No major complications occurred.

CONCLUSION

This study highlights the significance of recognizing PLSVC as a potential source of AF triggers. The single procedure success rate is low compared to patients without PLSVC. Further studies are warranted to enhance outcomes in this challenging AF population.

Oxytocin Attenuates Sympathetic Innervation with Inhibition of Cardiac Mast Cell Degranulation in Rats after Myocardial Infarction

Sympathetic hyperinnervation is the leading cause of fatal ventricular arrhythmia (VA) after myocardial infarction (MI). Cardiac mast cells cause arrhythmias directly through degranulation. However, the role and mechanism of mast cell degranulation in sympathetic remodeling remain unknown. We investigated the role of oxytocin (OT) in stabilizing cardiac mast cells and improving sympathetic innervation in rats. MI was induced by coronary artery ligation. Western blotting, immunofluorescence, and toluidine staining of mast cells were performed to determine the expression and location of target protein. Mast cells accumulated significantly in peri-infarcted tissues and were present in a degranulated state. They expressed OT receptor (OTR), and OT infusion reduced the number of degranulated cardiac mast cells post-MI. Sympathetic hyperinnervation was attenuated as assessed by immunofluorescence for tyrosine hydroxylase (TH). Seven days post-MI, the arrhythmia score of programmed electrical stimulation was higher in vehicle-treated rats with MI than in rats treated with OT. An in vitro study showed that OT stabilized mast cells via the phosphoinositide 3-kinase/protein kinase B (PI3K/Akt) signaling pathway. Further in vivo studies on OTR-deficient mice showed worsening mast cell degranulation and worsening sympathetic innervation. OT pretreatment inhibited cardiac mast cell degranulation post-MI and prevented sympathetic hyperinnervation, along with mast cell stabilization via the PI3K/Akt pathway. SIGNIFICANCE STATEMENT: This is the first study to elucidate the role and mechanism of oxytocin (OT) in inflammatory-sympathetic communication mediated sympathetic hyperinnervation after myocardial infarction (MI), providing new approaches to prevent fatal arrhythmias.

Catheter ablation of atrial fibrillation in a patient with interruption of the inferior vena cava complicated with persistent left superior vena cava

A 55-year-old woman of I-IVC complicated with PLSVC underwent catheter ablation for atrial fibrillation through right jugular vein access. TSP was achieved by electrocautery and the J-tip guidewire with the help of deflectable sheath and ICE. After PVI, the CS-PLSVC and LA-PLSVC connections were ablated within PLSVC.

Complete free wall isolation of arrhythmogenic persistent left superior vena cava

INTRODUCTION

Persistent left superior vena cava (PLSVC) is one of the major sources of triggers and drivers of atrial fibrillation (AF). There has been no established PLSVC ablation procedure to eliminate the arrhythmogenicity along the entire length of PLSVC.

METHODS AND RESULTS

A 70-year-old woman with a history of two previous catheter ablations for AF, mitral valvuloplasty, and an unroofed coronary sinus-type atrial septal defect closure underwent the redo AF ablations. The AF trigger and driver were identified within the patient's enlarged PLSVC. The AF was treated by complete PLSVC free wall isolation.

CONCLUSION

Complete PLSVC free wall isolation may be an effective ablation method to eliminate the arrhythmogenicity along the entire length of the PLSVC.

Persistent left superior vena cava isolation in patients with atrial fibrillation: Selective or empirical?

BACKGROUND

Persistent left superior vena cava (PLSVC) is the most prevalent form of thoracic venous abnormality and can serve as a significant arrhythmogenic source in atrial fibrillation (AF).

METHODS AND RESULTS

Among the 3950 patients who underwent radiofrequency ablation for AF between September 2014 to April 2020, 17 patients (mean age 59.4 ± 8.0 years, 64.7% male) with PLSVC were identified. Among them, nine patients (52.9%) had a prior history of pulmonary vein isolation (PVI) alone. Eight out of nine patients who experienced AF recurrence underwent PLSVC isolation with or without pulmonary vein (PV) reconnection. For the remaining eight patients (47.1%), PVI plus PLSVC isolation were performed during the index procedure. Ectopy originating from PLSVC was documented in 11 patients (64.7%) and successful PLSVC isolation was achieved in 16 patients (94.1%). After a median follow-up of 28.3 months, freedom from AF/ atrial tachycardia (AT) was observed in 13 patients (76.5%).

CONCLUSION

Empirical PLSVC isolation beyond PVI appears to be a feasible and safe strategy to prevent AF recurrence in patients with concomitant PLSVC.

The Sword and the Crown: Echocardiography for the Detection of a Rare Combination of Congenital Heart Disease

•Unexplained right heart enlargement should always prompt evaluation for shunts. •Scimitar syndrome occurs when the right pulmonary veins drain into the IVC. •Coronary sinus dilation should prompt suspicion for PLSVC. •PLSVC can be diagnosed with a bubble study through left-sided IV.

Accidental Diagnosis of Isolated Persistent Left Superior Vena Cava After an Elective Central Venous Access Procedure for Chronic Hemodialysis: Clinical Implications and Precautions From a Case Report

Persistent left superior vena cava (PLSVC) is the most frequent thoracic venous anatomical variant in the general population. Isolated PLSVC, without formation of the right superior vena cava, is described in 10% of cases of PLSVC only. While it can be associated with congenital heart disease, arrhythmias, and premature death, adult patients with PLSVC are mostly asymptomatic, and the diagnosis is usually accidental. We present the case of a 72-year-old male with end-stage renal disease who was started on urgent hemodialysis through a temporary non-tunneled femoral central venous catheter (CVC) in the SLED (slow low-efficiency dialysis) modality and later remained dependent on hemodialysis. At this stage, placement of a tunneled CVC in the right internal jugular vein was necessary and fluoroscopy guidance was not available. There were no complications during the procedure, but postoperative conventional chest radiography revealed an inadequate positioning of the CVC tip in the left hemithorax, crossing the midline. Subsequently, the diagnosis of PLSVC was obtained by performing a thoracic angio-CT scan, confirming CVC tip positioning inside the PLSVC, and also excluded the presence of cardiac defects or additional anatomical variations of the great vessels of the thorax. Early evaluation for the creation of autologous vascular access was started under our care, and there were no mechanical or other complications associated with hemodialysis sessions during early follow-up after discharge.

Provocation and Localization of Arrhythmogenic Triggers from Persistent Left Superior Vena Cava in Patients with Atrial Fibrillation

BACKGROUND

Although pulmonary vein isolation (PVI) is an established procedure for atrial fibrillation (AF), non-PV foci play a crucial role in AF recurrence. Persistent left superior vena cava (PLSVC) has been reported as critical non-PV foci. However, the effectiveness of provocation of AF triggers from PLSVC remains unclear. This study was designed to validate the usefulness of provoking AF triggers from PLSVC.

METHODS

This multicenter retrospective study included 37 patients with AF and PLSVC. To provoke triggers, AF was cardioverted, and re-initiation of AF was monitored under high-dose isoproterenol infusion. The patients were divided into two groups: those whose PLSVC had arrhythmogenic triggers initiating AF (Group A) and those whose PLSVC did not have triggers (Group B). Group A underwent isolation of PLSVC after PVI. Group B received PVI only.

RESULTS

Group A had 14 patients, whereas Group B had 23 patients. After a 3-year follow-up, no difference in the success rate for maintaining sinus rhythm was observed between the two groups. Group A was significantly younger and had lower CHADS2-VASc scores than Group B.

CONCLUSIONS

The provocation of arrhythmogenic triggers from PLSVC was effective for the ablation strategy. PLSVC electrical isolation would not be necessary if arrhythmogenic triggers are not provoked.

Cardiac Implantable Electronic Devices in Different Anatomical Types of Persistent Left Superior Vena Cava: Case Series and Brief Review of the Literature

Persistent left superior vena cava (PLSVC) is the most common congenital malformation of the thoracic venous system, being present in 0.3% to 0.5% of the general population. In the majority of the cases, PLSVC is asymptomatic, but in certain patients, it can manifest through several symptoms, such as arrhythmias and cyanosis, especially when it is associated with complex cardiac pathologies. The clinical significance of this venous anomaly depends on the anatomical variant of the drainage site. In this article, we will present the experience of our clinic, with patients with PLSVC that were diagnosed intraprocedurally, during cardiac pacemaker (CP) or cardioverter defibrillator (ICD) implantation, highlighting the technical difficulties that this anomaly poses for cardiac device implantation. Out of 4000 patients who were admitted to our clinic for CP or ICD implantation, we encountered six cases of PLSVC (four reported in this article and two previously published) corresponding to different anatomical types of this congenital anomaly. In all of these situations, we had to adapt our technique to the patient's anatomy in order to avoid certain complications, the most serious being the improper placement of the right ventricle lead at the level of the coronary sinus.

Catheter ablation for atrial fibrillation in patients with persistent left superior vena cava: Case series and systematic review

Introduction

Persistent left superior vena cava (PLSVC) is the most common form of thoracic venous abnormality. Catheter ablation (CA) for atrial fibrillation (AF) can be complicated by the existence of PLSVC, which could act as an important arrhythmogenic mechanism in AF.

Methods and results

We reported a case series of patients with PLSVC who underwent CA for AF at our center between 2018 and 2021. A systematic search was also performed on PubMed, EMBASE, and Web of Science for research reporting CA for AF in patients with PLSVC. Sixteen patients with PLSVC were identified at our center. Ablation targeting PLSVC was performed in 5 patients in the index procedures and in four patients receiving redo procedures. One patient experienced acute procedure failure. After a median follow-up period of 15 months, only 6 (37.5%) patients remained free from AF/atrial tachycardia (AT) after a single procedure. In the systematic review, 11 studies with 167 patients were identified. Based on the included studies, the estimated prevalence of PLSVC in patients undergoing CA for AF was 0.7%. Ablation targeting PLSVC was performed in 121 (74.7%) patients. Major complications in patients with PLSVC receiving AF ablation procedure included four cases of cardiac tamponades (2%), three cases of cardiac effusion (1.5%), one case of ischemic stroke, and three cases of phrenic nerve injury (1.5%) (one left phrenic nerve and two right phrenic nerve). Pooled analysis revealed that after a median follow-up period of 15.6 months (IQR 12.0–74.0 months), the long-term AF/AT-free rate was 70.6% (95% CI 62.8–78.4%, I² = 0.0%) (Central illustration). Different ablation strategies for PLSVC were summarized and discussed in the systematic review.

Conclusion

In patients with PLSVC, recurrence of atrial arrhythmia after CA for AF is relatively common. Ablation aiming for PLSVC isolation is necessitated in most patients. The overall risk of procedural complications was within an acceptable range.

Pictorial Essay: Understanding of Persistent Left Superior Vena Cava and Its Differential Diagnosis

Persistent left superior vena cava (PLSVC) is a rare congenital, thoracic, and vascular anomaly. Although PLSVCs generally do not have a hemodynamic effect, several types of PLSVC and some cardiac anomalies may manifest with clinical symptoms. The presence of PLSVC can render catheterization via left subclavian access difficult when placing a pacemaker or central venous catheter. As such, recognizing a PLSVC that is typically incidentally discovered can prevent complications such as vascular injury. Differentiating vessels found in a similar location as PLSVC is necessary when performing thoracic vascular procedures. This pictorial essay explains the multi-detector CT findings of a PLSVC, and provides a summary of other blood vessels that require differentiation during thoracic vascular procedures.

Pulsed Field Ablation for Persistent Superior Vena Cava: New Solution for an Old Problem

Persistent left superior vena cava (PLSVC) is a known arrhythmogenesis site in patients with atrial fibrillation. However, the optimal PLSVC isolation approach has remained unclear because of the potential risk of complications. The current study reports 2 cases of successful electrical PLSVC isolation using pulsed field ablation. (Level of Difficulty: Intermediate.).

Association of Depression With Atrial Fibrillation in South Korean Adults

IMPORTANCE

The risk of atrial fibrillation (AF) in people with depression is not fully known. Depression is associated with sympathetic activation and emotional stress, which might increase the risk of new-onset AF.

OBJECTIVE

To assess the incidence of new-onset AF in those with and without depression using data from a nationwide health care database.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study obtained data from the Korean National Health Insurance Service database and enrolled people who underwent a nationwide health checkup in 2009. People younger than 20 years and those with a history of heart valve surgery, previous diagnosis of mitral stenosis, or who were diagnosed with AF between January 1, 2002 and December 31, 2008 were excluded. The risk of new-onset AF (occurring between 2009 and 2018) was compared in people who were and were not diagnosed with depression within a year before the 2009 nationwide health checkup. Data were analyzed between August 1, 2020 and October 31, 2020.

EXPOSURE

Previous diagnosis of depression.

MAIN OUTCOMES AND MEASURES

Cumulative incidence and risk of new-onset AF between 2009 and 2018 in participants with and without depression. Kaplan-Meier analysis was conducted to assess incidence of AF, and Cox proportional hazards regression was used to calculate adjusted and unadjusted hazard ratios (HRs) and 95% CIs.

RESULTS

A total of 5 031 222 individuals with a mean (SD) age of 46.99 (14.06) years (2 771 785 men [55.1%]) were included in the analysis; of these individuals, 148 882 (3.0%) had a diagnosis of depression in the year before the 2009 health checkup and 4 882 340 (97%) did not. People with depression vs those without depression were older (aged 56.7 vs 46.7 years) and more likely to be women (96 472 [64.8%] vs 2 162 965 [44.3%]). Prevalence of hypertension, diabetes, dyslipidemia, and heart failure was higher in the depression group. The cumulative incidence of new-onset AF was significantly higher in people with depression vs without depression in the Kaplan-Meier analysis and showed steady divergence throughout 10 years of follow-up (cumulative incidence, 4.44% vs 1.92%; log-rank P < .001). After adjusting for covariates, depression was associated with a 25.1% increased risk of new-onset AF (HR, 1.25; 95% CI, 1.22-1.29; P < .001). People with recurrent episodes of depression showed even higher risk of new-onset AF (HR, 1.32; 95% CI, 1.27-1.37; P < .001). Young age and female sex had significant interactions with depression, which suggests that young people and women with depression may have an increased risk of new-onset AF.

CONCLUSIONS AND RELEVANCE

This study found that depression was associated with a significantly increased cumulative incidence and risk of new-onset AF. Recurrent episodes of depression were associated with even higher risk. These findings suggest the need for adequate screening for AF in people with depression, particularly in younger people and women.

Electrical Remodeling of Left Atrium Is a Better Predictor for Recurrence Than Structural Remodeling in Atrial Fibrillation Patients Undergoing Radiofrequency Catheter Ablation

We demonstrated that the electrical remodeling represented by low voltage zone is a better marker for the prediction of recurrence after radiofrequency catheter ablation as compared with structural remodeling measured by left atrium (LA) diameter. The study provides important clue that further deep dive into LA substrate research will be important to improve success rate of non-paroxysmal atrial fibrillation ablation.

Background and Objectives

Recurrence rates after radiofrequency catheter ablation (RFCA) in atrial fibrillation (AF) patients are not low especially in non-paroxysmal AF. The diameter of left atrium (LA) has been widely used to predict the recurrence after RFCA for decades. However, LA diameter represents structural remodeling of LA and does not reflect electrical remodeling. We aimed to determine the predictive value of electrical remodeling of LA which is represented by the amount of low voltage zone (LVZ).

Methods

We performed a retrospective cohort analysis of AF patients who underwent de novo RFCA in a single-center.

Results

A total of 3,120 AF patients with de novo RFCA were analyzed. Among these patients, 537 patients underwent an electroanatomic mapping with bipolar voltage measurement of LA. The diameter of LA and flow velocity of LA appendage (LAA) differed significantly according to quartile group of LVZ area and percentage: patients with high LVZ had large LA diameter and low LAA flow velocity (p<0.001). Freedom from late recurrence (LR) was significantly lower in patients with high LVZ area and percentage (p<0.001). The diameter and surface area of LA had area under curve (AUC) of 0.592 and 0.593, respectively (p=0.002 for both). The predictive value of LVZ area (AUC, 0.676) and percentage (AUC, 0.671) were both superior compared with LA diameter (p=0.011 and 0.027 for each comparison).

Conclusions

In conclusion, LVZ can predict freedom from LR after RFCA in AF patients. Predictive value was higher in parameters reflecting electrical rather than structural remodeling of LA.

Case report: Thoracoscopic ablation for a patient with atrial fibrillation and persistent left superior vena cava

Persistent left superior vena cava (PLSVC) is a relatively rare congenital anomaly in the general population. It plays an important role in initiating and maintaining atrial fibrillation (AF) in some patients. Radiofrequency catheter ablation is the major treatment for patients with AF and PLSVC in most publications. Here, we reported a case of thoracoscopic ablation for a patient with atrial fibrillation and persistent left superior vena cava. After preprocedural simulation using virtual reality, we successfully completed box-lesion, ablation line from superior vena cava to inferior vena cava, left atrial appendage (LAA) excision, and PLSVC ablation. It provides a new perspective on surgical treatment for patients with AF and PLSVC.

Atypical drainage of a persistent left vena cava superior into the left atrial appendage detected by multidimensional imaging: a case report and review of the literature

Background

While it is the most common thoracic venous anomaly, a persistent left vena cava superior may present in atypical variations, which are important to consider during clinical management.

Case presentation

Here we report a 35-year-old Caucasian female patient with drainage into the left atrial appendage who presented with shortness of breath accompanied by mild hypoxemia. Venous contrast filling in the context of pulmonary scintigraphy suspected an additional superior caval vein connected to the left atrial appendage. Diagnosis was confirmed by transesophageal echocardiography. Cardiac catheterization revealed a minor right-to-left shunt. The symptoms could be allocated to a bronchial asthma and treated according to guidelines. Cerebral lesions detected in the patient were due to a coincident multiple sclerosis rather than cerebral embolisms. Thus, the venous anomaly was classified as an incidental finding currently requiring no treatment.

Conclusions

To the best of our knowledge, this is the first report of a persistent left vena cava superior draining into the left atrial appendage.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13256-021-03210-9.

Persistent left superior vena cava: clinical importance and differential diagnoses

Persistent left superior vena cava (PLSVC) is the most common thoracic venous anomaly and may be a component of the complex cardiac pathologies. While it is often asymptomatic, it can lead to significant problems such as arrhythmias and cyanosis. Besides, it can cause serious complications during vascular interventional procedures or the surgical treatment of cardiac anomalies (CA). The clinical significance of PLSVC depends on the drainage site and the accompanying CA. In this article, we will describe the epidemiology, embryology, and anatomic variations of PLSVC. Possible accompanying CA and heterotaxy spectrum will be reviewed with the help of multidetector computed tomography (MDCT) images. Radiological pitfalls, differential diagnoses, and the clinical importance of PLSVC will be highlighted.

Beyond Pulmonary Vein Isolation in Nonparoxysmal Atrial Fibrillation: Posterior Wall, Vein of Marshall, Coronary Sinus, Superior Vena Cava, and Left Atrial Appendage

The optimal ablation strategy for non-paroxysmal atrial fibrillation remains controversial. Non-PV triggers have been shown to have a major arrhythmogenic role in these patients. Common sources of non-PV triggers are: posterior wall, left atrial appendage, superior vena cava, coronary sinus, vein of Marshall, interatrial septum, crista terminalis/Eustachian ridge, and mitral and tricuspid valve annuli. These sites are targeted empirically in selected cases or if significant ectopy is noted (with or without a drug challenge), to improve outcomes in patients with non-paroxysmal atrial fibrillation. This article focuses on summarizing the current evidence and the approach to mapping and ablation of these frequent non-PV trigger sites.