Radiofrequency Catheter Ablation for AV Nodal Reentrant Tachycardia Associated with Persistent Left Superior Vena Cava

Abstract

Slow AV nodal pathway ablation using RF is highly effective for patients with refractory AV nodal reentrant tachycardia (AVNRT). We report three catheter ablation cases using RF current in patients associated with persistent left superior vena cava (PLSVC). Three patients with drug refractory AVNRT of common variety were involved in this study. An electrode catheter introduced through the left subclavian vein inserted directly into the coronary sinus, a typical anatomical finding of PLSVC. The ablation procedure was initially performed at the posteroinferior region of Koch's triangle. A slow pathway potential could not be found from that area; nonsustained junctional tachycardia (NSJT) did not occur during the delivery of RF current; there was failure to eliminate slow AV nodal pathway conduction. The catheter then was moved into the bed of the proximal portion of the markedly enlarged coronary sinus. A slow AV nodal pathway potential was recorded through the ablation catheter, and the delivery of RF current caused NSJT in two patients. Complete elimination of slow AV nodal pathway conduction was accomplished in these two patients by this method. No adverse effects were provoked by this procedure. Catheter ablation of the slow AV nodal pathway guided by a slow pathway potential and the appearance of NSJT was feasible and safe in the area of the coronary sinus ostium in patients associated with PLSVC.

Persistent left superior vena cava associated with common type AV nodal reentrant tachycardia and AV reentrant tachycardia due to concealed left lateral accessory pathway

“…During a 10-year-period, 394 patients underwent ablation for AVNRT in our department and PLSVC was present in 5 of them (1.24%). The optimal ablation site of AV node slow pathway ablation in these patients remains unclear, due to atypical courses of the AV node slow pathway [1]. The area of the coronary sinus ostium and the posteroinferior region of Koch's triangle [2] are suggested sites of successful ablation.…”

Persistent left superior vena cava (PLSVC) with anomalous left hepatic vein drainage into the right atrium: role of imaging and clinical relevance

“…24,25 Other case series have also described the coexistence of left superior vena cava with a fistulous connection to the coronary sinus associated with Wolff Parkinson White syndrome, [26][27][28] atrio ventricular tachycardia or atrio ventricular nodal re-entry tachycardia. 23,29,30 It is possible that the abnormal development which leads to the presence of a left-sided superior vena cava could also result in abnormalities in conduction tissue, due to the close association of these areas during early intrauterine development. 25,27,28,30,31 In the electrophysiology literature, prevalence of left superior vena cava in patients undergoing pacemaker/ cardioverter defibrillator implantation is similar to that in the general population (0.3-0.5%).…”

“…It can also make placement of pacemaker leads and pulmonary artery catheters difficult because of the orientation of coronary sinus. 11,[21][22][23] Besides being associated with congenital diseases, PLSVC's most relevant clinical implication is the association with disturbances of cardiac impulse PLSVC drains into the left atrium creating a left to right shunt. [6][7][8][9][10] This lesion usually has little hemodynamic effect, although a variable degree of systemic cyanosis and clubbing may be seen.…”

Systemic venous anatomy in congenital heart disease: implications for electrophysiologic testing and catheter ablation

“…A dilated coronary sinus associated with persistent left SVC has been associated with arrhythmogenesis [32][33][34][35]. An enlarged coronary sinus may also affect the triangle of Koch with important implications for slow pathway ablation in atrioventricular nodal reentrant tachycardia [36][37][38]. Device implantation can also be more complicated in the setting of a persistent left SVC [39,40].…”