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Slow pathway cryoablation in a child with absent right superior caval vein and persistent left superior caval vein draining into the coronary sinus
International Journal of Cardiology 178 (2015) 178–180
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Slow pathway cryoablation in a child with absent right superior caval vein and persistent left superior caval vein draining into the coronary sinus Alfredo Di Pino a,⁎, Elio Caruso a, Placido Gitto a, Luca Costanzo b, Salvatore Patanè c, Giuseppe Calvagna c a b c
Department of Pediatric Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital Centro Cardiologico Pediatrico del Mediterraneo, San Vincenzo Hospital, Taormina, ME, Italy Cardio-toraco-vascular Department, Division of Angiology, Ferrarotto-Policlinic Hospital, University of Catania, Catania, Italy Cardiology unit, S. Vincenzo Hospital Taormina, ME, Italy
a r t i c l e
i n f o
Article history: Received 20 October 2014 Accepted 22 October 2014 Available online 23 October 2014 Keywords: Absent right superior caval vein Persistent left superior caval vein Coronary sinus Slow pathway cryoablation
1. Case report A 12 year old boy was referred to our institution for recurrent episodes of paroxysmal supraventricular tachycardia. The baseline ECG showed non-sinus atrial rhythm with heart rate of 75 beats/min (Fig. 1-A). The echocardiogram revealed a normal cardiac structure with persistence of a left superior caval vein (PLSCV) draining into a dilated coronary sinus (CS). After a written informed consent, a transcatheter ablation procedure was planned because of agonist sport practice and parent choice. A fast anatomic map of the inferior caval vein, right atrium, CS and PLSCV was performed using an electroanatomic 3D mapping system (CARTO 3). Thereafter, 2 diagnostic tetrapolar and decapolar electrocatheters, were positioned respectively at the his bundle region and inside the CS. During the electrophysiological study, a discontinuous AV node conduction curve was demonstrated with a 120 ms jump and anterograde refractory period of the fast pathway of 330 ms. Continuous incremental atrial pacing showed sustained a slow pathway conduction with PR N RR interval. Typical slow–fast atrioventricular nodal reentry tachycardia (AVNRT) with a cycle length of 330 ms was easily induced using a single premature stimulus (Fig. 1-B). Because of lack of access to the right superior caval vein (RSCV), a stop-flow angiography into the brachiocephalic vein via the CS and PLSCV was performed and confirmed the absence of the RSCV (Fig. 2-A). A further angiography was performed to clearly delineate the CS ostium to obtain a landmark for Koch triangle anatomy (Fig. 2-B). Thereafter, using angiographic landmarks and electroanatomical mapping, a 6 minute cryoablation was performed in a typical postero-septal site where a typical slow pathway potential was recorded just near the tricuspid annulus in a slight ventricular position (Fig. 2-C–D). After this lesion AVNRT was still inducible although not sustained. Thereafter, we performed 2 more 6 minute cryolesions in the same region to create a line of ablation from the ventricular site to the atrial site just near the CS ostium. After this linear cryoablation AVNRT was no more inducible both in the basal state then during isoproterenol infusion and dual AV node physiology disappeared. The procedure time was 120 min ⁎ Corresponding author at: Arrhythmia Service Centro Cardiologico Pediatrico del Mediterraneo — S. Vincenzo Hospital Contrada Sirina, Taormina, Italy. E-mail address: [email protected] (A. Di Pino).
http://dx.doi.org/10.1016/j.ijcard.2014.10.141 0167-5273/© 2014 Elsevier Ireland Ltd. All rights reserved.
and the fluoroscopy time was 5 min. There were no acute complications and no recurrences of AVNRT at 1-year follow-up.
2. Discussion PLSCV draining into the CS is a relatively common anatomical variant of the systemic venous system. However, PLSCV with the absence of the RSCV in visceroatrial situs solitus is an extremely rare venous variant with a reported incidence ranging from 0.7 to 0.13% [1,2]. In these cases the RSCV is totally absent, and the right brachiocephalic vein drains through the innominate vein into a PLSCV that usually connects to the CS, although it can also connect directly to the left atrium if unroofing of the CS is present [3]. This anatomic venous variant has been associated with a higher incidence of brady and tachyarrhythmias including sinus node dysfunction, atrioventricular block, atrioventricular reciprocating tachycardia using an accessory AV connection and AVNRT [2,4]. In such peculiar anatomical arrangement slow pathway ablation may be challenging because of the extreme dilation of the CS, potential anatomical variations of the AV node position and the presence of multiple slow inputs into the AV node [4–7]. Because of this, after electroanatomic reconstruction of the right atrium and diagnosis of AVNRT, we preferred to ablate the slow pathway using cryoenergy in order to minimize the risk of AV block in a such young child [8]. Moreover, it is note worthy that even with this anatomic arrangement we identified typical slow pathway potentials in the posterior third of the Kock triangle that was previously delimitated using angiographic and electroanatomic landmarks. It has been reported that cryoablation of AVNRT is associated with a reduced acute procedural success and increased risk of early recurrences when compared with traditional radiofrequency ablation [9]. Thus, we used a linear lesion cryoablation strategy in order to improve the acute and long-term outcome [10]. In conclusion, we present one more case of absent RSCV and PLSCV draining into CS associated with the occurrence of AVNRT. To the best of our knowledge this is the first report of a child with this anatomical arrangement with a successful slow pathway ablation using cryoenergy and minimally fluoroscopic approach. Conflict of interest The authors report no conflict of interest.
A. Di Pino et al. / International Journal of Cardiology 178 (2015) 178–180
179
Fig. 1. Panel A: Baseline ECG showing non-sinus atrial rhythm with heart rate of 75 beats/minute. Panel B: Endocavitary electrocardiographic trace showing induction of slow-fast atrioventricular nodal reentry tachycardia.
Acknowledgments The authors of this manuscript have certified that they adhere to the statement of ethical publishing as appears in the International Journal of Cardiology. References [1] C.C. Lenox, J.R. Zuberbuhler, S.C. Park, et al., Absent right superior vena cava with persistent left superior vena cava: implications and management, Am. J. Cardiol. 45 (1980) 117–122. [2] U.M.D. Bartram, S.M.D. Van Praagh, J.C.M.D. Levine, et al., Absent right superior vena cava in visceroatrial situs solitus, Am. J. Cardiol. 80 (1997) 175–183. [3] J.Y. Choi, R.H. Anderson, F.J. Macartney, et al., Absent right superior caval vein (vena cava) with normal atrial arrangement, Br. Heart J. 57 (1987) 474–478. [4] C. Ratnasamy, S.F. Idriss, M.P. Carboni, R.J. Kanter, Arrhythmias in children having a single left superior vena cava and minimal structural heart disease, J. Cardiovasc. Electrophysiol. 20 (2009) 182–186.
[5] K. Okishige, J.D. Fisher, Y. Goseki, et al., Radiofrequency ablation of AV nodal reentrant tachycardia associated with persistent left superior vena cava, Pacing Clin. Electrophysiol. 20 (1997) 2213–2218. [6] K. Sakabe, N. Fucuda, K. Wakayama, T. Nada, H. Shinohara, Y. Tamura, Radiofrequency ablation for atrioventricular nodal reentrant tachycardia in a patient with persistent left superior vena cava, Int. J. Cardiol. 95 (2004) 355–357. [7] S. Ernst, F. Ouyang, C. Linder, et al., Modulation of the slow pathway in the presence of a persistent left superior caval vein using the novel magnetic navigation system Niobe, Europace 6 (1) (2004) 10–14. [8] G.P. Kimman, L.J. Jordaens, Transvenous radiofrequency catheter ablation of atrioventricular nodal reentrant tachycardia and its pitfalls: a rationale for cryoablation? Int. J. Cardiol. 108 (2006) 6–11. [9] A. Opel, S. Murray, N. Kamath, et al., Cryoablation versus radiofrequency ablation for treatment of atrioventricular nodal reentrant tachycardia: cryoablation with 6-mm-tip catheters is still less effective than radiofrequency ablation, Heart Rhythm. 7 (2010) 340–343. [10] R.J. Czosek, J. Anderson, B.S. Marino, et al., Linear lesion cryoablation for the treatment of atrioventricular nodal re-entry tachycardia in pediatrics and young adults, PACE 33 (2010) 1304–1311.
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A. Di Pino et al. / International Journal of Cardiology 178 (2015) 178–180
Fig. 2. Panel A: Contrast mean injection into the brachiocephalic vein via the coronary sinus and left superior caval vein that shows the absence of right superior caval vein (Antero-Posterior view). Panel B: The angiography showing the dilated coronary sinus ostium was used as an angiographic landmark for Koch triangle anatomy (30° Right anterior oblique view). Panel C: Right anterior oblique fluoroscopic image showing the position of decapolar diagnostic catheter in coronary sinus (CS), quadripolar His bundle cather (His) and cryoablation catheter (Cryocath). Panel D: 3D electroanatomical mapping system (CARTO 3) showing the same catheters in panel C in right anterior oblique view.
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Slow pathway cryoablation in a child with absent right superior caval vein and persistent left superior caval vein draining into the coronary sinus Alfredo Di Pino a,⁎, Elio Caruso a, Placido Gitto a, Luca Costanzo b, Salvatore Patanè c, Giuseppe Calvagna c a b c
Department of Pediatric Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital Centro Cardiologico Pediatrico del Mediterraneo, San Vincenzo Hospital, Taormina, ME, Italy Cardio-toraco-vascular Department, Division of Angiology, Ferrarotto-Policlinic Hospital, University of Catania, Catania, Italy Cardiology unit, S. Vincenzo Hospital Taormina, ME, Italy
a r t i c l e
i n f o
Article history: Received 20 October 2014 Accepted 22 October 2014 Available online 23 October 2014 Keywords: Absent right superior caval vein Persistent left superior caval vein Coronary sinus Slow pathway cryoablation
1. Case report A 12 year old boy was referred to our institution for recurrent episodes of paroxysmal supraventricular tachycardia. The baseline ECG showed non-sinus atrial rhythm with heart rate of 75 beats/min (Fig. 1-A). The echocardiogram revealed a normal cardiac structure with persistence of a left superior caval vein (PLSCV) draining into a dilated coronary sinus (CS). After a written informed consent, a transcatheter ablation procedure was planned because of agonist sport practice and parent choice. A fast anatomic map of the inferior caval vein, right atrium, CS and PLSCV was performed using an electroanatomic 3D mapping system (CARTO 3). Thereafter, 2 diagnostic tetrapolar and decapolar electrocatheters, were positioned respectively at the his bundle region and inside the CS. During the electrophysiological study, a discontinuous AV node conduction curve was demonstrated with a 120 ms jump and anterograde refractory period of the fast pathway of 330 ms. Continuous incremental atrial pacing showed sustained a slow pathway conduction with PR N RR interval. Typical slow–fast atrioventricular nodal reentry tachycardia (AVNRT) with a cycle length of 330 ms was easily induced using a single premature stimulus (Fig. 1-B). Because of lack of access to the right superior caval vein (RSCV), a stop-flow angiography into the brachiocephalic vein via the CS and PLSCV was performed and confirmed the absence of the RSCV (Fig. 2-A). A further angiography was performed to clearly delineate the CS ostium to obtain a landmark for Koch triangle anatomy (Fig. 2-B). Thereafter, using angiographic landmarks and electroanatomical mapping, a 6 minute cryoablation was performed in a typical postero-septal site where a typical slow pathway potential was recorded just near the tricuspid annulus in a slight ventricular position (Fig. 2-C–D). After this lesion AVNRT was still inducible although not sustained. Thereafter, we performed 2 more 6 minute cryolesions in the same region to create a line of ablation from the ventricular site to the atrial site just near the CS ostium. After this linear cryoablation AVNRT was no more inducible both in the basal state then during isoproterenol infusion and dual AV node physiology disappeared. The procedure time was 120 min ⁎ Corresponding author at: Arrhythmia Service Centro Cardiologico Pediatrico del Mediterraneo — S. Vincenzo Hospital Contrada Sirina, Taormina, Italy. E-mail address: [email protected] (A. Di Pino).
http://dx.doi.org/10.1016/j.ijcard.2014.10.141 0167-5273/© 2014 Elsevier Ireland Ltd. All rights reserved.
and the fluoroscopy time was 5 min. There were no acute complications and no recurrences of AVNRT at 1-year follow-up.
2. Discussion PLSCV draining into the CS is a relatively common anatomical variant of the systemic venous system. However, PLSCV with the absence of the RSCV in visceroatrial situs solitus is an extremely rare venous variant with a reported incidence ranging from 0.7 to 0.13% [1,2]. In these cases the RSCV is totally absent, and the right brachiocephalic vein drains through the innominate vein into a PLSCV that usually connects to the CS, although it can also connect directly to the left atrium if unroofing of the CS is present [3]. This anatomic venous variant has been associated with a higher incidence of brady and tachyarrhythmias including sinus node dysfunction, atrioventricular block, atrioventricular reciprocating tachycardia using an accessory AV connection and AVNRT [2,4]. In such peculiar anatomical arrangement slow pathway ablation may be challenging because of the extreme dilation of the CS, potential anatomical variations of the AV node position and the presence of multiple slow inputs into the AV node [4–7]. Because of this, after electroanatomic reconstruction of the right atrium and diagnosis of AVNRT, we preferred to ablate the slow pathway using cryoenergy in order to minimize the risk of AV block in a such young child [8]. Moreover, it is note worthy that even with this anatomic arrangement we identified typical slow pathway potentials in the posterior third of the Kock triangle that was previously delimitated using angiographic and electroanatomic landmarks. It has been reported that cryoablation of AVNRT is associated with a reduced acute procedural success and increased risk of early recurrences when compared with traditional radiofrequency ablation [9]. Thus, we used a linear lesion cryoablation strategy in order to improve the acute and long-term outcome [10]. In conclusion, we present one more case of absent RSCV and PLSCV draining into CS associated with the occurrence of AVNRT. To the best of our knowledge this is the first report of a child with this anatomical arrangement with a successful slow pathway ablation using cryoenergy and minimally fluoroscopic approach. Conflict of interest The authors report no conflict of interest.
A. Di Pino et al. / International Journal of Cardiology 178 (2015) 178–180
179
Fig. 1. Panel A: Baseline ECG showing non-sinus atrial rhythm with heart rate of 75 beats/minute. Panel B: Endocavitary electrocardiographic trace showing induction of slow-fast atrioventricular nodal reentry tachycardia.
Acknowledgments The authors of this manuscript have certified that they adhere to the statement of ethical publishing as appears in the International Journal of Cardiology. References [1] C.C. Lenox, J.R. Zuberbuhler, S.C. Park, et al., Absent right superior vena cava with persistent left superior vena cava: implications and management, Am. J. Cardiol. 45 (1980) 117–122. [2] U.M.D. Bartram, S.M.D. Van Praagh, J.C.M.D. Levine, et al., Absent right superior vena cava in visceroatrial situs solitus, Am. J. Cardiol. 80 (1997) 175–183. [3] J.Y. Choi, R.H. Anderson, F.J. Macartney, et al., Absent right superior caval vein (vena cava) with normal atrial arrangement, Br. Heart J. 57 (1987) 474–478. [4] C. Ratnasamy, S.F. Idriss, M.P. Carboni, R.J. Kanter, Arrhythmias in children having a single left superior vena cava and minimal structural heart disease, J. Cardiovasc. Electrophysiol. 20 (2009) 182–186.
[5] K. Okishige, J.D. Fisher, Y. Goseki, et al., Radiofrequency ablation of AV nodal reentrant tachycardia associated with persistent left superior vena cava, Pacing Clin. Electrophysiol. 20 (1997) 2213–2218. [6] K. Sakabe, N. Fucuda, K. Wakayama, T. Nada, H. Shinohara, Y. Tamura, Radiofrequency ablation for atrioventricular nodal reentrant tachycardia in a patient with persistent left superior vena cava, Int. J. Cardiol. 95 (2004) 355–357. [7] S. Ernst, F. Ouyang, C. Linder, et al., Modulation of the slow pathway in the presence of a persistent left superior caval vein using the novel magnetic navigation system Niobe, Europace 6 (1) (2004) 10–14. [8] G.P. Kimman, L.J. Jordaens, Transvenous radiofrequency catheter ablation of atrioventricular nodal reentrant tachycardia and its pitfalls: a rationale for cryoablation? Int. J. Cardiol. 108 (2006) 6–11. [9] A. Opel, S. Murray, N. Kamath, et al., Cryoablation versus radiofrequency ablation for treatment of atrioventricular nodal reentrant tachycardia: cryoablation with 6-mm-tip catheters is still less effective than radiofrequency ablation, Heart Rhythm. 7 (2010) 340–343. [10] R.J. Czosek, J. Anderson, B.S. Marino, et al., Linear lesion cryoablation for the treatment of atrioventricular nodal re-entry tachycardia in pediatrics and young adults, PACE 33 (2010) 1304–1311.
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A. Di Pino et al. / International Journal of Cardiology 178 (2015) 178–180
Fig. 2. Panel A: Contrast mean injection into the brachiocephalic vein via the coronary sinus and left superior caval vein that shows the absence of right superior caval vein (Antero-Posterior view). Panel B: The angiography showing the dilated coronary sinus ostium was used as an angiographic landmark for Koch triangle anatomy (30° Right anterior oblique view). Panel C: Right anterior oblique fluoroscopic image showing the position of decapolar diagnostic catheter in coronary sinus (CS), quadripolar His bundle cather (His) and cryoablation catheter (Cryocath). Panel D: 3D electroanatomical mapping system (CARTO 3) showing the same catheters in panel C in right anterior oblique view.