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Atrioventricular nodal reentry tachycardia in apatient with interrupted inferior vena cava withazygos continuation and persistent left superiorvena cava

전남대학교 의과대학 내과학교실 윤 남 식 / 조 정 관Nam-Sik Yoon, MD, Jeong-Gwan Cho, MDDepartment of Cardiovascular Medicine, Chonnam National University Hospital, Gwangju, Korea

ABSTRACTA 40-year-old female patient was referred for ablation of recurrent episodes of supraventricular tachycardia.Echocardiography revealed a persistent left superior vena cava (PLSVC). Cardiac electrophysiology studyrevealed typical atrioventricular nodal reentry tachycardia (AVNRT). Coronary sinus (CS) catheter wasintroduced through the PLSVC from the left subclavian vein. The other catheters were introduced through theright superior vena cava and the azygos vein from the femoral vein because the inferior vena cava (IVC) wasinterrupted. Thus, in a patient with an interrupted IVC with azygos continuation and a PLSVC, we performed asuccessful catheter ablation of AVNRT with conventional fluoroscopy guidance at the anterior portion of theproximal coronary sinus.

Key words: ■ atrioventricular nodal reentry tachycardia ■ interrupted inferior vena cava ■ persistent left superior vena cava

Introduction

Recently, the first catheter ablation of AVNRT

had been reported in a patient with the combination

of an anomalous IVC with azygos continuation and

a PLSVC. They used non-fluoroscopic navigation

systems in the ablation procedures. However, we

could perform successful catheter ablation of

AVNRT with conventional fluoroscopy guidance,

without aids of navigation systems.

Case

A 40-year-old female patient was referred to

our hospital for ablation of recurrent episodes of

reentrant tachycardia. The chest X-ray was

normal. The electrocardiogram obtained during the

attack of her typical symptoms showed a narrow

QRS complex, regular tachycardia, terminated with

intravenous adenosine injection (Figure 1).

Echocardiography revealed a markedly enlarged CS,

which suggested the presence of a PLSVC. Chest CT

angiogram revealed interrupted IVC and azygos

continuation to superior vena cava (Figure 2).

Cardiac electrophysiology study was performed

after written informed consent. A CS catheter

was introduced through the PLSVC from the left

subclavian vein. Catheters for HRA, RV and His

Received: December 15, 2010 Revision Received: February 27, 2011Accepted: March 30, 2011Correspondence: Jeong-Gwan Cho, MD, PhD, FACC, FHRS, Professor,Director of Cardiac Electrophysiology Lab, Chonnam National UniversityHospital, 671 Jebongro, Dong-gu, Gwangju 501-757, KoreaTel: 82-62-220-6242, Fax: 82-62-223-3105E-mail: chojg@unitel.co.kr

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bundle area were introduced through the right

superior vena cava and azygos vein from the

femoral vein because the IVC was interrupted

(Figure 3). We used a deflectable catheter in order

to record the His bundle potential and conventional

quadripolar electrode catheters were located at

HRA and RV. Rapid ventricular pacing demonstrated

concentric retrograde atrial activation with

decremental property. Supraventricular tachycardia

was induced by single atrial premature depolarization

after AH jump and the result of entrainment pacing

was consistent with typical AVNRT.

After CS venogram (Figure 3A, 3B), we tried to

map the slow pathway potential and precise

course of the His bundle. The slow pathway

potential could not be mapped from that area.

The His bundle potential was recorded at just

above the roof of the dilated CS ostium. A

deflectable 7 Fr ablation catheter was introduced

through the azygos vein and right superior vena

cava. Ablation was attempted from the bottom of

CS ostium using anatomical approach. AVNRT

Figure 1. ECG showed narrow QRS regular tachycardia of 150/min without visible P wave, suggesting AV nodal reentrytachycardia.

Figure 2. Chest CT angiogram revealed interruptedinferior vena cava and azygos continuation to superiorvena cava (right posterior oblique view).

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was not able to be eliminated from the floor and

mid part of CS ostium, although a junctional

rhythm appeared during radiofrequency delivery.

Atrioventricular nodal dual physiology was

eliminated by positioning the ablation catheter

more anteriorly inside the very proximal CS

(Figure 3C, 3D). Junctional rhythm appeared

again during radiofrequency delivery. Afterward,

no AH jumps or atrioventricular nodal echoes

were induced at baseline state nor during

isoproterenol infusion. The patient was

discharged without any complications. The

patient has been well without recurrence of the

tachycardia.

Figure 3. Coronary sinus venogram showed a huge dilated coronary sinus (white arrows: coronary sinus, white arrowheads: His catheter, A: RAO view, B: LAO view). Coronary sinus catheter was introduced through a persistent leftsuperior vena cava from the left subclavian vein. Catheters for right atrium, right ventricle and His bundle wereintroduced through the azygos vein and superior vena cava from both femoral veins because of the interruption of IVC(black arrow heads: ablation catheter, stars: coronary sinus catheter, C: RAO view, D: LAO view).

A B

C D

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Thus, we performed a successful catheter

ablation of AVNRT in a patient with combined

congenital anomaly of an interrupted IVC with

azygos continuation and a PLSVC.

Discussion

The malformations of the systemic venous

connection to the heart may be summarized as

follows: (a) Left superior vena cava connected to

the CS, interrupted IVC and absent right superior

vena cava; (b) Left superior vena cava connected

to the left atrium, due to incorporation of the CS

into the left atrial cavity; (c) Right superior vena

cava or IVC draining into the left atrium; (d)

Total anomalous systemic venous connection to

the left atrium, usually combined with atrial

isomerism; (e) Cor triatriatum dexter.1 Persistent

left superior vena cava is a relatively common

anomaly of the systemic venous system, with an

incidence of 0.3~0.5% in the general population.

This incidence is higher in patients with

congenital heart disease and in patients with

atrioventricular connection abnormalities.2

Prevalence of interrupted IVC is 0.6~2.0% in

patients with congenital heart disease and less

than 0.3% among otherwise normal patients.3

To the best of our knowledge, the first catheter

ablation of AVNRT had been reported in a patient

with the combination of an anomalous IVC with

azygos continuation and a PLSVC like our case by

Arias et al recently.4 They used non-fluoroscopic

navigation systems in the ablation procedures.

However in our case, successful catheter ablation

was performed with conventional fluoroscopy

guidance at the anterior portion of the proximal

coronary sinus. Sakabe et al.5 reported successful

ablation at posteroinferior region of Koch’s

triangle with anatomical approach. Such variations

of successful sites might be due to various course

of the atrioventricular nodal slow pathway in

patients with PLSVC, which might be affected by

the dilated CS ostium due to PLSVC.5

Of note, catheter ablation of AVNRT in patients

with a PLSVC requires more careful attention to

avoid the risk for atrioventricular block, because

of the extraordinary anatomy of Koch’s triangle

and the unusual course of the His bundle due to

the huge dilation of the CS ostium.

References

1. Mazzucco A, Bortolotti U, Stellin G, Gallucci V. Anomalies ofthe systemic venous return: a review. J Card Surg. 1990;5:122-133.

2. Katsivas A, Koutouzis M, Nikolidakis S, Lazaris E, Arealis G,Kyriakides ZS. Persistent left superior vena cava associatedwith common type AV nodal reentrant tachycardia and AVreentrant tachycardia due to concealed left lateral accessorypathway. Int J Cardiol. 2006;113:E124-125.

3. Timmers GJ, Falke TH, Rauwerda JA, Huijgens PC. Deep veinthrombosis as a presenting symptom of congenitalinterruption of the inferior vena cava. Int J Clin Pract.1999;53:75-76.

4. Arias MA, Castellanos E, Puchol A, Valverde I, Pachon M,Garcia-Cosio MD, Rodriguez-Padial L. Atrioventricular nodaltachycardia in a patient with anomalous inferior vena cavawith azygos continuation and persistent left superior venacava. Pacing Clin Electrophysiol. 2009;32:1357-1358.

5. Sakabe K, Fukuda N, Wakayama K, Nada T, Shinohara H,Tamura Y. Radiofrequency catheter ablation for atrioventricularnodal reentrant tachycardia in a patient with persistent leftsuperior vena cava. Int J Cardiol. 2004;95:355-357.