© 2004 by European Society of Cardiology
CASE REPORT
Radiofrequency catheter ablation of an accessory pathway through an anomalous inferior vena cava with azygos continuation
Department of Cardiology, Hospital Vall d'Hebrón, Av Vall d'Hebron 119-129 Barcelona 08035, Spain
Manuscript submitted 8 April 2003. Accepted after revision 9 November 2003.
*Corresponding author. Tel./fax: +34-932746166. E-mail address: 28637erf{at}comb.es (E.R. Font).
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Abstract |
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A 59-year-old man with Wolff–Parkinson–White syndrome and an infrahepatic interruption of his inferior vena cava with an azygos continuation underwent a successful ablation of a right anteroseptal accessory pathway with a femoral approach through the azygos vein and superior vena cava.
Key Words: ablation, congenital anomaly, Wolff–Parkinson–White syndrome, azygos vein
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Introduction |
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Infrahepatic interruption of the inferior vena cava is a congenital anomaly found in 1.3–3.0% of patients with congenital heart disease [1
–3]. In this condition, the inferior vena cava is interrupted above the level of the renal veins and, as a result, the systemic venous drainage below the interruption is via an enlarged azygos vein usually into the superior vena cava; in contrast, the hepatic veins typically drain through the residual orifice of the inferior vena cava into the right atrium [1,3,4]. We report a case of accessory pathway catheter ablation in a patient with an infrahepatic interruption of inferior vena cava with azygos continuation. |
Case report |
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A 59-year-old man, with a long history of palpitations, was referred to our department for evaluation and treatment. A 12-leads surface ECG showed a short PR interval with a Wolff–Parkinson–White type preexcitation (Fig. 1). Physical examination revealed no anomalous findings and no enlargement of the cardiac silhouette was noted on routine chest X-ray.
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An electrophysiological study was performed in our laboratory after obtaining written informed consent. Two quadripolar catheters were inserted percutaneously into the right femoral vein. When the catheters reached the level of the cardiac silhouette, no electrical activity could be registered, and they could not be advanced to the His bundle position in the heart. A Doppler echocardiographic examination was then performed, showing indirect signs of interruption of the inferior vena cava with azygos continuation, as the echogenic contrast injected at the femoral vein entered the atrium by the superior vena cava. A pigtail catheter was then advanced throughout the femoral vein, azygos vein and the superior vena cava into the right atrium, confirming the diagnosis. Using the same approach, two catheters were placed in the right atrium, a 7F steerable catheter (EP Technologies, San Jose, CA, USA) for recording the His bundle and atrial activity and a 7F, 4 mm tip standard ablation catheter (EP Technologies, San Jose, CA, USA) for mapping the accessory pathway. A 6F tetrapolar electrode catheter (Bard Electrophysiology, Lowell, MA, USA) was placed in the right ventricular apex through the right subclavian vein (Fig. 2). An orthodromic atrioventricular reciprocating tachycardia was induced during programmed atrial stimulation. Endocardial mapping of the tricuspid annulus in sinus rhythm, showed the area of earliest ventricular activation at the level of the right anteroseptal region near the His bundle position (Fig. 2A). Radiofrequency current was then applied abolishing the preexcitation in the first second of the application (Fig. 2B). A His bundle potential could be recorded through the distal bipole of the ablation catheter at the end of the radiofrequency pulse. After the ablation, ventricular pacing demonstrated decremental retrograde VA conduction.
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Following the procedure, digital angiography was performed to confirm the initial diagnosis of infrahepatic interruption of the inferior vena cava with azygos continuation (Fig. 3).
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Discussion |
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To our knowledge, radiofrequency catheter ablation in a patient with an infrahepatic interruption of inferior vena cava with azygos continuation has not been previously reported. In the presence of this anomaly, the access to the right cavities from the femoral approach must be made via the azygos vein and the superior vena cava. As a result, the positioning and manipulation of the recording and mapping catheters are more difficult due to the longer course and the sharp angulation of the azygos vein entering the superior vena cava. However, this case illustrates the feasibility of the ablation procedure under these unusual circumstances.
The anomaly is often associated with other cyanotic or acyanotic congenital cardiac disorders, abnormalities of cardiac position such as dextrocardia and polysplenia or asplenia [1,3,4]. However, in this patient no other anomaly was found.
Radiofrequency catheter ablation is the treatment of choice for patients with a history of palpitations and a functional accessory pathway. The most common access to the heart is from the femoral approach. The technique is highly effective and safe. However, when the accessory pathway is located in the right anteroseptal region, close to the His bundle, the possibility of inadverted atrioventricular block has to be taken into account. In normal circumstances, the reported rate of this complication is around 2–5% in most of the series [5]. The presence of a distorted anatomy may significantly increase this percentage, as may occur in the setting of congenital heart disease. Some authors [6] have recommended the upper approach (via the jugular or subclavian vein), in order to improve catheter stability and therefore achieving higher temperature in the tip–tissue interface. In our case, we preferred use of the lower approach leaving the upper approach to achieve more stability of the right ventricular catheter for security back-up ventricular pacing.
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References |
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[1] Anderson R.C., Adams P.A., Burke B. Anomalous inferior vena cava with azygos continuation (infrahepatic interruption of the inferior vena cava). J Pediatr 1961; 50: 370–383.
[2] Mayo J., Gray R., St Louis E., et al. Anomalies of the inferior vena cava. Am J Radiol 1983; 140: 339–343.
[3] Chuang V.P., Mena C.E., Hoskins P.A. Congenital anomalies of the inferior vena cava. Review of the embryogenesis and presentation of a simplified classification. Br J Radiol 1974; 47: 206–213.
[4] Suthar A.L., Nanda N.C., Harris P.J. Two-dimensional and Doppler echocardiographic identification of infrahepatic interruption of inferior vena cava with azygos continuation. Pacing Clin Electrophysiol 1983; 6: 963–971.[CrossRef][Medline]
[5] Calkins H. Catheter ablation of anteroseptal and midseptal accessory pathways. In Singer I. (Ed.), et al. Nonpharmacological therapy of arrhythmias for the 21st century 1998; Armonk, NY Futura Publishing Co., Inc pp. 117–138.
[6] Schlüter M. and Kuck K.H. Ablation of anteroseptal atrioventricular accessory pathways. In Huang S.K.S. (Ed.). Radiofrequency catheter ablation of cardiac arrhythmias 1995; Armonk, NY Futura Publishing Co., Inc pp. 335–347.
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