Congenital anomalies of the venous system are a challenge for cardiac catheterization and radiofrequency ablation. This article describes ablation of atrioventricular nodal re-entrant tachycardia performed solely through the azygos continuation in a patient with inferior vena cava interruption

Gellér, László Alajos

Merkely, Béla Péter

Osztheimer, István

Széplaki, Gábor

Özcan, E.

Emin E. Özcan

István Osztheimer

Gábor Széplaki

Béla Merkely

László Gellér

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Canadian Journal of Cardiology

Successful Ablation of Atrioventricular Nodal Re-entrant Tachycardia in a Patient With Interruption of Inferior Vena Cava and Azygos Continuation

Özcan, Emin Evren

Repository of the Academy's Library

Successful ablation of atrioventricular nodal re-entrant tachycardia in a patient with interruption of inferior vena cava and azygos continuation.

013) 1741.e9e1741.e11 www.onlinecjc.caCanadian Journal of Cardiology 29 (2Case ReportSuccessful Ablation of Atrioventricular Nodal Re-entrantTachycardia in a Patient With Interruption of Inferior VenaCava and Azygos ContinuationEmin E. Özcan, MD, István Osztheimer, MD, Gábor Szeplaki, MD, PhD,Bela Merkely, MD, PhD, DSc, and László Geller, MD, PhDDepartment of Cardiology, Semmelweis University, Heart Center, Budapest, HungaryABSTRACTCongenital anomalies of the venous system are a challenge for cardiaccatheterization and radiofrequency ablation. This article describesablation of atrioventricular nodal re-entrant tachycardia performedsolely through the azygos continuation in a patient with inferior venacava interruption.Received for publication May 22, 2013. Accepted August 15, 2013.Corresponding author: Dr László Geller, Semmelweis University, HeartCenter, Gaál József street 9, 1122, Budapest, Hungary. Tel.: þ36-20-3658330; fax: þ36-1-4586842.E-mail: laszlo.geller@gmail.comSee page 1741.e10 for disclosure information.0828-282X/$ - see front matter  2013 Canadian Cardiovascular Society. Publishehttp://dx.doi.org/10.1016/j.cjca.2013.08.014RESUMELes anomalies congenitales du système veineux representent un deﬁpour le catheterisme cardiaque et l’ablation par radiofrequence. Cetarticle decrit l’ablation de la tachycardie par reentree nodale effectueeuniquement par la veine azygos chez un patient ayant une interruptionde la veine cave inferieure.Interruption of the inferior vena cava (IVC) with azygos azygos vein, a second steerable decapolar catheter (Inquiry,continuation is an uncommon congenital venous abnormality.Accessing the heart through the transfemoral route for elec-trophysiological studies is really challenging in this anomaly.We report a case of atrioventricular nodal re-entrant tachy-cardia (AVNRT) ablation performed using a femoral approachthrough the azygos continuation.Case PresentationA 58-year-old female patient was referred to our institutionfor catheter ablation of drug-refractory recurrent supraven-tricular tachycardia. At the beginning of the procedure,a decapolar steerable catheter (Inquiry, 6F; St Jude Medical, StPaul, MN) was routinely advanced into the femoral vein. Thecatheter exhibited an unusual angulation at the abdominallevel, and no electrical activity could be recorded when itreached the cardiac silhouette. When the catheter wasadvanced more distally, it passed into the superior vena cavaand the right atrium. This route was suggestive of an inter-ruption of the IVC with continuation of the azygos vein.Angiography with a pigtail catheter was performed tocorroborate the diagnosis. Because it was not possible toadvance a quadripolar catheter through the angulation of the6F) was used. One catheter was placed in the coronary sinus(CS) and the other one was placed in the right ventricle(Fig. 1, A and B). Programmed stimulation from the CSostium induced AVNRT (started with a 104-ms AV jumpand echo beat; RR cycle length, 471 ms; VA interval, 28 ms atthe proximal CS).Responses to entrainment with ventricular overdrivepacing indicated the diagnosis of AVNRT (Fig. 2A).Entrainment was repeated multiple times and similar resultswere obtained. Additionally, QRS complex fusion was notobserved during ventricular entrainment. A 4-mm ablationcatheter (7F Blazer II asymmetrical curve catheter; BostonScientiﬁc, Natick, MA) was also advanced through the azygoscontinuation. After the compact AV node region was deter-mined by recording His potential (Fig. 1C), radiofrequencyenergy was delivered (40 W, 60C) at the posterior aspect ofthe Koch triangle, where the slow pathway potentials wereobserved (Figs. 1D and 2B). After ablation, there was noobservation of dual AV node conduction properties and noarrhythmia was induced. Total procedure time was 106minutes, and ﬂuoroscopy time was 33.7 minutes. Contrast-enhanced computed tomography was performed to corrobo-rate the diagnosis and rule out other abnormalities duringfollow-up (Fig 1E).DiscussionThe prevalence of interruption of the IVC with azygoscontinuation is 0.1%-0.3% in patients without congenitalheart disease.1,2 The IVC receives blood from both kidneysand lower extremities, passes posterior to the diaphragmaticd by Elsevier Inc. All rights reserved.Figure 1. (A) Right anterior oblique and (B) left anterior oblique views showing the catheters advanced to heart chambers through azygos vein andsuperior vena cava, respectively. (C) Anterior-posterior view showing the ablation catheter at para-Hisian region (asterisk). (D) Anterior-posterior viewshowing the ablation catheter at slow pathway region (arrow). (E) Right posterior oblique view of 3-dimensional reconstruction of the contrast-enhanced computed tomographic scan. Note that the hepatic vein is connected directly to the right atrium. Abl, ablation catheter; CS, coronarysinus catheter; HV, hepatic vein; RA, right atrium; RV, right ventricle; SVC, superior vena cava; catheter; VA, azygos vein.1741.e10 Canadian Journal of CardiologyVolume 29 2013crura, and enters the thorax as the azygos vein. Occasionally,interruption starts at lower levels, and veins from thesestructures drain to the azygos vein. Afterward, the azygos veinjoins the superior vena cava at the right paratracheal space.3 Atortuous course of the azygos continuation complicates cath-eter ablation from the lower extremities. Successful slowpathway ablations have been reported through the jugular andsubclavian veins in patients with interruption of the IVC withazygos continuation.4 However, these ablation approaches areassociated with increased radiation exposure and discomfortfor both patient and physician. Orientation and manipulationof catheters is also different from usual procedures. In somecases, the IVC might not be truly occluded and the ablationcatheter could be advanced through the permeable hypoplasticIVC.5 All previously reported AVNRT ablations in patientswith interruption of the IVC with azygos continuation wereperformed by a combined (superior and femoral) approach.4,5Fortunately, the azygos vein in our patient was enlargedenough to advance and manipulate 3 catheters. To the best ofour knowledge, AVNRT ablation solely through the azygoscontinuation has not yet been reported.Congenital anomalies of the venous system may limitcatheter ablation of AVNRT. This report highlights theimportance of identifying these anomalies during the proce-dure as well as a proper approach depending on the anatomy.Funding SourcesSupported by the János Bolyai Research Scholarship of theHungarian Academy of Sciences and Hungarian ScientiﬁcResearch FounD (OTKA 105555 LG, GSZ).DisclosuresThe authors have no conﬂicts of interest to disclose.References1. Trigaux JP, Vandroogenbroek S, De Wispelaere JF, Lacrosse M, Jamart J.Congenital anomalies of the inferior vena cava and left renal vein: evalu-ation with spiral CT. J Vasc Interv Radiol 1998;9:339-45.Figure 2. Intracardiac tracings consistent with atrioventricular nodal re-entrant tachycardia (AVNRT). (A) VAV (ventricle-atrium-ventricle) responseafter cessation of right ventricular overdrive pacing excludes a diagnosis of atrial tachycardia. Post-pacing intervaletachycardia cycle lengthdifference (PPI-TCL) was 157 ms, stimulus-to-atrialeventriculoatrial differences (SA-VA) was 131 ms and indicate the diagnosis of AVNRT. (B) Slowpathway potentials were observed at the site of successful ablation. PPI, post-pacing interval; SA, stimulus-to-atrial interval; TCL, tachycardia cyclelength; VA, ventriculoatrial interval.Özcan et al. 1741.e11Catheter Ablation Through Azygos Continuation2. Chuang VP, Mena CE, Hoskins PA. Congenital anomalies of the inferiorvena cava. Review of embryogenesis and presentation of a simpliﬁedclassiﬁcation. Br J Radiol 1974;47:206-13.3. Bass JE, Redwine MD, Kramer LA, Huynh PT, Harris JH Jr. Spectrum ofcongenital anomalies of the inferior vena cava: cross-sectional imagingﬁndings. Radiographics 2000;20:639-52.4. Miranda R, Simpson CS, Nolan RL, et al. Superior approach for radio-frequency ablation of atrio-ventricular nodal reentrant tachycardia ina patient with anomalous inferior vena cava and azygos continuation.Europace 2010;12:908-9.5. Arbelo E, Caballero E, Medina A. Successful slow pathway ablation foratrioventricular nodal re-entrant tachycardia via a hypoplastic inferior venacava in a patient with an azygos continuation. Europace 2008;10:467-8.

Successful ablation of atrioventricular nodal re-entrant tachycardia in a patient with interruption of inferior vena cava and azygos continuation

Oezcan, EMİN EVREN

Osztheimer, Istvan

Szeplaki, Gabor

Merkely, Bela

Geller, Laszlo

Dokuz Eylul University Research Information System

https://avesis.deu.edu.tr/publication/details/77d18ebe-f540-4d18-8243-9c758cf32057/oai

Successful ablation of atrioventricular nodal re-entrant tachycardia in a patient with interruption of inferior vena cava and azygos continuation

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