Catheter ablation for atrial fibrillation in patients with persistent left superior vena cava: Case series and systematic review

Abstract

IntroductionPersistent left superior vena cava (PLSVC) is the most common form of thoracic venous abnormality. Catheter ablation (CA) for atrial fibrillation (AF) can be complicated by the existence of PLSVC, which could act as an important arrhythmogenic mechanism in AF.Methods and resultsWe reported a case series of patients with PLSVC who underwent CA for AF at our center between 2018 and 2021. A systematic search was also performed on PubMed, EMBASE, and Web of Science for research reporting CA for AF in patients with PLSVC. Sixteen patients with PLSVC were identified at our center. Ablation targeting PLSVC was performed in 5 patients in the index procedures and in four patients receiving redo procedures. One patient experienced acute procedure failure. After a median follow-up period of 15 months, only 6 (37.5%) patients remained free from AF/atrial tachycardia (AT) after a single procedure. In the systematic review, 11 studies with 167 patients were identified. Based on the included studies, the estimated prevalence of PLSVC in patients undergoing CA for AF was 0.7%. Ablation targeting PLSVC was performed in 121 (74.7%) patients. Major complications in patients with PLSVC receiving AF ablation procedure included four cases of cardiac tamponades (2%), three cases of cardiac effusion (1.5%), one case of ischemic stroke, and three cases of phrenic nerve injury (1.5%) (one left phrenic nerve and two right phrenic nerve). Pooled analysis revealed that after a median follow-up period of 15.6 months (IQR 12.0–74.0 months), the long-term AF/AT-free rate was 70.6% (95% CI 62.8–78.4%, I2 = 0.0%) (Central illustration). Different ablation strategies for PLSVC were summarized and discussed in the systematic review.ConclusionIn patients with PLSVC, recurrence of atrial arrhythmia after CA for AF is relatively common. Ablation aiming for PLSVC isolation is necessitated in most patients. The overall risk of procedural complications was within an acceptable range.

Clinical implication of persistent left superior vena cava isolation for atrial fibrillation: Author's reply

“…4 We acknowledge potential procedural complications, such as left phrenic nerve palsy, cardiac tamponade, and ischemic stroke during PLSVC ablation. While Gao et al 5 reported a procedural complication incidence of up to 7.5%, our study did not observe major complications. They proposed PLSVC isolation as routine in highly experienced centers with ensured safety.…”

Persistent left superior vena cava isolation in patients with atrial fibrillation: Selective or empirical?

“…Besides, ablation from both the endocardial and CS has been reported in cases. Due to the anatomical variations of PLSVC, procedural complications such as left phrenic nerve palsy, cardiac tamponade and ischemic stroke have been reported in previous studies 20–22 . However, no major complications were observed in our study.…”

Pulsed field ablation of a persistent left superior vena cava in recurrent paroxysmal atrial fibrillation and its effect on the mitral isthmus: A case report

“…Persistent left superior vena cava (LSVC) is the most common congenital malformation of the thoracic veins, with an overall incidence of 0.3%–1%, 1 and has a well-established arrhythmogenic potential in the context of paroxysmal and persistent atrial fibrillation (AF). 2 Traditionally, catheter ablation of this anatomic variant is performed using radiofrequency (RF) lesions, aiming either at the ablation of focal triggers within the LSVC or at the creation of circumferential lesions to achieve electrical disconnection of the vein.…”