We present a 43-year-old patient with paroxysmal supraventricular tachycardia. In the process
of catheter ablation, we found interruption of the inferior vena cava with azygos continuation
with incomplete situs inversus. In this patient, we adopted the lower approach via the anomalous
inferior vena cava and azygos continuation to achieve stability of radiofrequency catheter
for right posteroseptal accessory pathway, and successfully abolished the preexcitation

Liu, Qi-ming

Ouyang, Fei-fan

Zhou, Sheng-hua

English

Via Medica Journals

CASE REPORTCardiology Journal2009, Vol. 16, No. 2, pp. 164–167Copyright © 2009 Via MedicaISSN 1897–5593164 www.cardiologyjournal.orgAddress for correspondence: Qi-ming Liu, MD, Department of Cardiology, the Second Xiangya Hospital of Central SouthUniversity, Changsha, Hunan, 410011, China, tel: +86 731 5292013, fax: +86 731 5533525, e-mail: qimingliu@yahoo.com.cnReceived: 28.08.2008 Accepted: 26.10.2008Successful radiofrequency ablation ofa right posteroseptal accessory pathwaythrough an anomalous inferior vena cava andazygos continuation in a patient withincomplete situs inversusQi-ming Liu1, Sheng-hua Zhou1, Fei-fan Ouyang21Department of Cardiology, the Second Xiangya Hospital of Central South University, Changsha, Hunan, China22nd Medizinische Abteilung, Allgemeines Krankenhaus St. Georg, Hamburg, GermanyAbstractWe present a 43-year-old patient with paroxysmal supraventricular tachycardia. In the processof catheter ablation, we found interruption of the inferior vena cava with azygos continuationwith incomplete situs inversus. In this patient, we adopted the lower approach via the anoma-lous inferior vena cava and azygos continuation to achieve stability of radiofrequency catheterfor right posteroseptal accessory pathway, and successfully abolished the preexcitation. (Cardiol J2009; 16, 2: 164–167)Key words: ablation, congenital anomaly, accessory pathway, azygos veinIntroductionComplete situs inversus is a rare anomaly witha prevalence of 0.02% in the general population [1].Infrahepatic interruption of the inferior vena cava(IVC) is a congenital anomaly found in 1.3–3.0% ofpatients with congenital heart disease [2], and oc-curs in 8–18% of patients with dextrocardia [3, 4].In this condition, the IVC is interrupted above therenal portion, and systemic venous flow from belowthe interruption usually drains into the superiorvena cava (SVC) via an enlarged azygos vein [5].Although there are a few reports of radiofrequencycatheter ablation of cardiac arrhythmias via this ano-malous IVC and azygos continuation [6–10], thereis no report of catheter ablation in such a patientwith isolated levoversion of the heart and incom-plete situs inversus, to the best of our knowledge.In this case report, we describe a successful abla-tion of the right posteroseptal accessory pathway(AP) in a patient with such an anomaly.Case reportA 43-year-old female patient was admitted to theSecond Xiangya Hospital because of frequent tachy-cardia attacks accompanied by palpitation. Twelve-lead ECG showed discrete preexcitation with a po-sitive delta wave in leads I, aVL, and V2 to V6, andnegative delta wave in leads II, III, aVF, and V1,exhibiting a normal sinus rhythm, which suggesteda posteroseptal AP. An ECG recorded during an epi-sode of palpitations showed a narrow QRS complextachycardia with a cycle length of 178 ms (Fig. 1),and a P wave followed the QRS complex during thetachycardia; the morphology of the P tachycardiawave was unable to be appreciated due to superim-position of the ST-T segment. Physical examinationrevealed no anomalous findings, and no enlarge-ment of the cardiac silhouette was noted on routi-ne chest X-ray.After obtaining informed written consent, anelectrophysiological study was performed. A quadri-165Qi-ming Liu et al., RF ablation of AP through an anomalous IVC and AZYwww.cardiologyjournal.orgpolar catheter (Biosense-Webster, USA) was inser-ted from the right internal jugular vein and advan-ced into the coronary sinus (CS). When anotherquadripolar catheter was inserted from the rightfemoral vein, it could not reach the right atriumdirectly from the IVC. When the catheters reachedthe level of the cardiac silhouette, no electrical ac-tivity could be recorded. Subsequently, a pigtail ca-theter was advanced throughout by the same appro-ach and inferior venocavography revealed an azy-gos continuation of the IVC, in which the IVC wasinterrupted above the renal segment and the veno-us flow drained into the SVC through a dilated azy-gos vein (Fig. 2). Two catheters were advanced andplaced at the right ventricular apex and the HBregion via the anomalous inferior vena cava and azy-gos continuation. The anterograde and retrogradeeffective refractory periods of the AP were 220 msand 320 ms, respectively. An orthodromic atrioven-tricular reciprocating tachycardia (AVRT) was indu-ced repeatedly during programmed right ventricu-lar stimulation. The earliest ventricular and atrialactivation site were the proximal CS during sinusrhythm and AVRT, respectively.Figure 1. Surface 12-lead ECG and intracardiac recordings during tachycardia; A. Surface 12-lead ECG showspreexcitation with a positive delta wave in I, aVL, and V2–V6 leads, and delta wave initially positive in II, III, aVF, andV1 leads, suggesting a posteroseptal accessory pathway; B. Tracing during atrioventricular reentrant tachycardia areECG leads I, II, V1, V5, and intracardiac electrograms recorded from a map catheter close to the HB region withearliest atrial activation in the posteroseptal area (ABLd, ABLp, ABLu). A catheter at the HB region (HBEp, HBEd),a catheter in the coronary sinus (CSp, CSd), and a catheter at the right ventricular apex (RVA). Note the earliest atrialactivation at the HB region.Figure 2. Left (45°) anterior oblique radiographic viewershowing the interruption of the inferior vena cava andazygos continuation to the superior vena cava (SVC) bydigital angiography; AZY — azygos vein; RA — rightatrium; PA — pulmonary artery.A B166Cardiology Journal 2009, Vol. 16, No. 2www.cardiologyjournal.orgFollowing that, a deflectable 7 F 4-mm tip ca-theter (Biosense-Webster Inc, USA) was advancedinto the ostium of the CS via the azygos vein andSVC, which drew back the electrode in right ven-tricular and HB owing to interference with the abla-tion catheter. The local ventricular activation pre-ceded the onset of the delta wave by 34 ms. A ra-diofrequency ablation target temperature of 55°Cwas started at 30 W and increased to 50 W for 60 sunder continuous fluoroscopy to reach the targettemperature. The preexcitation was successfullyeliminated 5 s from the onset of the energy delive-ry (Fig. 3), then right ventricular pacing demonstra-ted retrograde atrioventricular conduction blockalso post ablation.Follow up Doppler echocardiographic examina-tion was performed, with isolated levoversion of theheart, reversely positioned liver and spleen, andsigns of interruption of the IVC with azygos conti-nuation (the contrast injected at the femoral veinentered the right atrium by the SVC). However, noother anomaly was found including polysplenia orasplenia. The patient was free of palpitation attacksand recurrence of the preexcitation observable onthe 12-lead ECG during 12 months post-ablation fol-low-up.DiscussionThe most common anomaly involving IVC isthe absence of its infrahepatic segment and connec-tion to the SVC through the azygos vein [1–4]. Azy-gos continuation is seen in 0.6% of patients withcongenital heart disease [11]. In this condition, theIVC is interrupted above the level of the renal ve-ins and, as a result, the systemic venous drainagebelow the interruption is via an enlarged azygosvein, usually into the SVC; in contrast, the hepaticveins typically drain through the residual orifice ofthe IVC into the right atrium [2]. The anomaly isoften associated with other cyanotic or acyanoticcongenital cardiac disorders and abnormalities ofcardiac position such as dextrocardia and polyspleniaor asplenia [5]. However, incomplete situsinversus was only found in this type of patient. The-re have been a few case reports of radiofrequencycatheter ablation of supraventricular arrhythmias inpatients with dextrocardia [6–10], complete situsFigure 3. Right (30°) and left (45°) anterior oblique radiographic viewer show the mapping catheter (ABL) at thesuccessful ablation site in the ostium of coronary sinus (CS), a multipolar catheter inside the CS, and an ablationcatheter at the ostium of CS (A, B). Recording at the site of successful ablation, a single radiofrequency delivery atthe site resulted in the accessory pathway being eliminated after 5 s. From above to below: four surface ECG leads(I, II, aVF, V5), ablation catheter distal, proximal and unipolar (ABLd ABLp, ABLu), and CS catheter distal, proximalCSd, CSp) recordings (C).ABC167Qi-ming Liu et al., RF ablation of AP through an anomalous IVC and AZYwww.cardiologyjournal.orginversus, and no other cardiac and systemic veno-us abnormalities. In such cases, radiofrequencyablation could be successfully performed with noparticular difficulties (e.g. right instead of left, cloc-kwise instead of counter-clockwise). It has been re-ported that successful radiofrequency ablation of APand atrial flutter through an anomalous inferior venacava and azygos continuation. Recently Taniguchiet al. [9] reported that in a patient with dextrocardiawith complete situs inversus, an accessory connec-tion between the coronary sinus and left ventriclewas achieved with a right cubital vein approach.Radiofrequency catheter ablation is the treat-ment of choice for symptomatic patients with a func-tional accessory pathway. The most common accessto the heart is from the femoral approach. When theAP is located in the right septal region, close to theHis bundle, the possibility of inadvertent atrioven-tricular block has to be taken into account. In nor-mal circumstances, the reported rate of this com-plication is around 2–5% in most of the series [12].The presence of a distorted anatomy may signifi-cantly increase this percentage, as may occur in thesetting of congenital heart disease. In order to ablatesuccessfully, therefore, some surgeons have recom-mended the upper approach (via the jugular or sub-clavian vein), and adopted a higher temperature inthe tip tissue interface. In this patient, the radio-frequency current failed to abolish the preexcita-tion via the right internal jugular vein due to insta-bility of the catheter. In our case, we think the lo-wer approach leaving the upper approach via ananomalous IVC and azygos continuation allowed toachieve stability of radiofrequency catheter forright posteroseptal AP.ConclusionsFor a patient with right posteroseptal accessorypathway combined with an anomalous inferior venacava and azygos continuation the ablation can beachieved successfully, but there are some difficul-ties including the instability of radiofrequencycatheter and higher risk of complications, so itneeds to be well-skilled.AcknowledgementsThe authors do not report any conflict of inte-rest regarding this work.References1. Nugent EW, Pauth WH, Edwards JE. The pathology, pathophysio-logy, recognition and treatment of congenital heart disease. In:Schlant RC ed. Hurst’s the heart. McGraw-Hill, New York 1994:1807–1808.2. Mayo J, Gray R, St Louis E, Grosman H, McLoughlin M, Wise D.Anomalies of the inferior vena cava. Am J Roentgenol, 1983;140: 339–345.3. Garg N, Agarwal BL, Modi N, Radhakrishnan S, Sinha N.Dextrocardia: An analysis of cardiac structures in 125 patients.Int J Cardiol, 2003; 88: 143–155.4. Fulcher AS, Turner MA. Abdominal manifestations of situsanomalies in adults. Radiographics, 2002; 22: 1439–1456.5. Suthar AL, Nanda NC, Harris PJ. Two-dimensional and Dopplerechocardiographic identification of infrahepatic interruption ofinferior vena cava with azygos continuation. Pacing Clin Elec-trophysiol, 1983; 6: 963–971.6. Pak HN, Hwang C, Kim YH. Twin atrioventricular node associat-ed with interruption of the inferior vena cava and atrioventricularnodal reentrant tachycardia. J Electrocardiol, 2006; 39: 400–403.7. Kilic A, Amasyali B, Kose S, Aytemir K, Kursaklioglu H, Lenk MK.Successful catheter ablation of a right-sided accessory pathwayin a child with interruption of the inferior vena cava and azygoscontinuation. Int Heart J, 2005; 46: 537–541.8. Malavasi VL, Casali E, Rossi L, Grazia Modena M. Radiofre-quency catheter ablation of common atrial flutter in a patientwith anomalous inferior vena cava and azygos continuation.Pacing Clin Electrophysiol, 2005; 28: 733–735.9. Taniguchi H, Miyauchi Y, Kobayashi Y et al. Radiofrequencycatheter ablation of a coronary sinus-ventricular accessory connec-tion in dextrocardia with complete situs inversus and an anomalousinferior vena cava. Pacing Clin Electrophysiol, 2005; 28: 164–167.10. Guerra Ramos JM, Font ER, Moya I, Mitjans A. Radiofrequencycatheter ablation of an accessory pathway through an anomalousinferior vena cava with azygos continuation. Europace, 2004; 6:134–137.11. Anderson RC, Adams P Jr, Burke B. Anomalous inferior venacava with azygos continuation (infrahepatic interruption of theinferior vena cava). Report of 15 new cases. J Pediatr, 1961; 59:370–383.12. Calkins H. Catheter ablation of anteroseptal and midseptalaccessory pathways. In: Singer I et al. eds. Nonpharmacologicaltherapy of arrhythmias for the 21st century. Futura PublishingCo., Inc. Armonk, NY 1998: 117–138.

Successful radiofrequency ablation of a right posteroseptal accessory pathway through an anomalous inferior vena cava and azygos continuation in a patient with incomplete situs inversus

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Successful radiofrequency ablation of a right posteroseptal accessory pathway through an anomalous inferior vena cava and azygos continuation in a patient with incomplete situs inversus

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