Congenital venous anomalies are uncommon, incidental findings encountered during adult interventional electrophysiology procedures. Femoral venous access is conventionally used during cardiac electrophysiology studies to gain access to the heart. The chance finding of an inferior vena cava anomaly may preclude the performance of these procedures from the femoral approach. We describe two cases in which we were able to successfully perform different radiofrequency catheter ablation procedures in the presence of an unusual venous anomaly, the left-sided IVC. doi: https://doi.org/10.12669/pjms.36.6.2947 How to cite this:Awan RA, Khanzada MF, Mumtaz Z, Qadir F. Successful radio-frequency catheter ablation of two cases of supraventricular tachycardia via a left-sided inferior vena cava. Pak J Med Sci. 2020;36(6):---------. doi: https://doi.org/10.12669/pjms.36.6.2947 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Background: Clinically manifest cardiac involvement occurs in perhaps 5% of patients with sarcoidosis. The three principal manifestations of cardiac sarcoidosis (CS) are conduction abnormalities, ventricular arrhythmias, and heart failure. We report a patient whose initial manifestation of cardiovascular involvement was sudden cardiac arrest due to sustained ventricular tachycardia. Presentation: A 40 year old lady with a history with no significant past medical history presented one year ago with haemodynamically stable RBBB morphology with inferior axis wide complex tachycardia consistent with VT which reverted to sinus rhythm with intravenous metoprolol. Echo revealed normal LV function. She was then discharged on beta blockers and advised to get CT chest on follow up. CT chest revealed bilateral hilar lymphadenopathy and she was referred to pulmonologist. Diagnosis and Management: 6 months later she presented with incessant hemodynamically stable ventricular tachycardia that remained sustained for 24 hours despite intravenous beta blockers, amiodarone and verapamil requiring multiple cardioversions. She was sedated, mechanically ventilated and started on oral Propranolol and intravenous methylprednisolone with the suspicion of CS. Patient reverted to sinus rhythm within 24 hours of intravenous steroids. Patient’s PET scan confirmed the diagnosis CS. Follow-up and Outcomes: Though the diagnosis of early CS is difficult, detection and initiation of specific treatment is vital. Although the present case lacks a definitive tissue diagnosis, the patient meets accepted criteria for CS. ICD was implanted in this patient. Keywords: Wide Complex Tachycardia 1, Cardiac Sarcoidosis 2, Incessent 3, ICD 4, PET 5

Objectives: Misconceptions regarding various physical activities after pacemaker implantation can severely limit a patient's lifestyle and very little in terms of patient education has been done to correct it. This study; by means of both verbal, and provision of brochure for education of patients; at the time of discharge and then reinforcing by questioning again at subsequent visit, aims to correct it. Methodology: A Quasi- experimental design of study carried out on consecutive patients implanted permanent pacemaker at electrophysiology department NICVD Karachi. Patients were discharged with an educational brochure and practical application of various daily life activities after assessment of related knowledge at baseline with reassessment at 1st visit. A questionnaire of 25 daily activities was developed and tested. Patients perception of safety of various daily activities both at baseline and at 1 week follow up were noted along with socio- demographic data of the patient. Results: A total of128 patients were interviewed at baseline, out of which 115 showed up for follow-up after one week. Male patients were 59.4% (76) of the sample and 47.7% were illiterate. Mean age of the patient was 60.31 ± 12.81 years. Only 11/128 at baseline, and 59/115 after intervention, answered all questions correctly. The percentages at baseline and 1 week follow up for: driving (82% vs. 99.1%; p=0.005), climbing stairs (75% vs. 97.4%; p<0.001), sleeping on the side of pacemaker (60.2% vs. 91.3%; p=0.001), usage of mobile phone (28.1% vs. 96.5%; p<0.001), for electric iron (54.7% vs. 94.8%; p<0.001), electrical switches (16.4% vs. 96.5%; p<0.001), microwave ovens (54.7% vs. 84.3%; p<0.001), electrical sewing machines (58.6% vs. 93.0%; p=0.106), UPS and electricity generators (52.3% vs. 87.8%; p=0.003), electric motors (63.3% vs. 91.3%; p<0.001), undergoing X-Ray irradiation (68% vs. 96.5%; p<0.001), and ultrasound imaging (65.6% vs. 93.9%; p=0.005). Conclusion: Many pacemaker patients' misperception leading to unnecessarily restricted lifestyle can be corrected by simple measures such as distribution of brochures and in hospital implementation of those activities which can be resumed with in hospital stay thereby benefitting the patient more than just with implantation. Distribution of these brochures and counseling with practical application should therefore be standardized and made as part of routine for all pacemaker patients. Keywords: mobile phone usage 1, MRI scanning 2, patient education 3, permanent pacemaker 4.

Background: Femoral vein access is the preferred approach for advancing multiple catheters via the inferior vena cava (IVC) to the heart during routine cardiac electrophysiology study and catheter ablation. Compared to acquired venous abnormalities, congenital inferior vena cava anomalies are encountered rather infrequently in adult electrophysiology procedures and their presence may pose technical procedural challenges. Presentation: We describe 2 cases in which we were able to successfully perform cardiac electrophysiological procedures in the presence of a complex congenital venous anomaly, the left sided IVC. First case was 30 year old gentleman presented with history of recurrent episodes of supraventricular tachycardia terminated with AV nodal blocking agents. Second case was 21 year old boy with WPW syndrome and recurrent supra-ventricular tachycardia. Diagnosis and Management: We managed to pass the EP catheters in both cases with a bit difficulty and angulation, while given I/V heparin to reduce the risk of thrombosis and confirmed the position of catheters via subclavian venous placement of a guidewire. In first case, typical AV node reentry tachycardia was induced which was mapped and ablated in the slow pathway region. In second case, right posterior accessory pathway was ablated at 6 0’clock. CT angiography of the abdominal veins was performed which confirmed the finding of left sided IVC. Follow-up and Outcomes: Abnormalities of the IVC are relatively uncommon. But it is an important condition that may be encountered by electrophysiologist. Catheter ablation of the slow AV nodal pathway and right posterior accessory pathway was safely and successfully performed with this unusual venous anomaly. Keywords: SVT, LEFT IVC, RFA