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

Mini-Sternotomy for Aortic Valve Replacement with Concomitant Ablation of the Pulmonary Vein and Persistent Left Superior Vena Cava: A Case Report

A 79-year-old man with severe aortic valve stenosis and atrial fibrillation was referred to our department for surgery. Computed tomography revealed persistent left superior vena cava. Lower mini-sternotomy was performed. The left atrial appendage was amputated before ablation of the persistent left superior vena cava. The jaw of the ablation device was passed behind the pulmonary veins using a tip-lighted articulating dissector. Finally, aortic valve replacement was completed. Aortic valve replacement with concomitant pulmonary vein and persistent left superior vena cava ablation via lower mini-sternotomy is a safe and less invasive alternative.

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.