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

Three-dimensional mapping and superior approach for catheter ablation in patients without inferior vena cava access

Catheter ablation for tachyarrhythmia via superior approach has been used in patients without possible inferior vena cava access such as in cases of venous occlusion or complex anomaly. Difficulty in catheter manipulation, instability, number of required vascular access, and radiation exposure of operator had been described in the procedure. Application of three-dimensional (3-D) mapping system in catheter ablation via superior approach could navigate the guiding catheter and provide more precise ablation. We reported four cases receiving catheter ablation due to atrioventricular nodal reentry tachycardia, atrial fibrillation, and right ventricular arrhythmia via superior approach facilitated by 3-D mapping system with fewer vascular access and catheters.

Spermatic vein sclero-embolization through basilic vein access: A short communication

Objectives: To depict the basics of percutaneous spermatic vein sclero-embolization through a right basilic vein access and to qualitatively assess the reduced discomfort and pain of this access compared to the femoral one through a VAS scale. Methods: From February 2019 to March 2020, 20 varicocele sclero-embolizations through a right basilic vein were performed and retrospectively evaluated. All patients were men with a median age of 24.5 years. Treatment technique is described, as well as mean radiation dose and procedural time, and complication rates. Results: Technical success was obtained in all patients. 1 access site complication requiring conversion to femoral access occurred. 100% of patients reported only a "mild" pain ranging from 1 to 3 on VAS scale, suggesting a comfortable access for this procedure. Conclusions: Basilic vein access determines easy left and right spermatic vein catheterization, rapid ambulation as well as easy monitoring of the access site for post-procedural evaluations.

Atrial fibrillation ablation in a single atrium with inferior vena cava interruption

Common atrium (CA), also called three-chambered heart, is one of the rare congenital anomalies, defined by a complete absence of the atrial septum, eventually associated with malformation of the atrioventricular (AV) valves. We report the case of a 57-year-old woman with CA complicated with Eisenmenger syndrome and inferior vena cava interruption, who suffered from symptomatic persistent atrial fibrillation (AF). She underwent an initial successful pulmonary vein isolation procedure. A repeat procedure for perivalvular atrial flutter was complicated with inadvertent complete AV block, due to unusual AV node location in this challenging anatomy.

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.