Systematic review of electrophysiology procedures in patients with obstruction of the inferior vena cava

Abstract

Aims The objective of the study was to conduct a systematic review to describe and compare the different approaches for performing cardiac electrophysiology (EP) procedures in patients with interrupted inferior vena cava (IVC) or equivalent entities causing IVC obstruction. Methods We conducted a structured search to identify manuscripts reporting EP procedures with interrupted IVC or IVC obstruction of any aetiology published up until August 2020. No restrictions were applied in the search strategy. We also included seven local cases that met inclusion criteria. Results The analysis included 142 patients (mean age 48.9 years; 48% female) undergoing 143 procedures. Obstruction of the IVC was not known before the index procedure in 54% of patients. Congenital interruption of IVC was the most frequent cause (80%); and, associated congenital heart disease (CHD) was observed in 43% of patients in this setting. The superior approach for ablation was the most frequently used strategy (52%), followed by inferior approach via the azygos or hemiazygos vein (24%), transhepatic approach (14%), and retroaortic approach (10%). Electroanatomical mapping (58%), use of long sheaths (41%), intracardiac echocardiography (19%), transesophageal echocardiography (15%) and remote controlled magnetic navigation (13%) were used as adjuncts to aid performance. Ablation was successful in 135 of 140 procedures in which outcomes were reported. Major complications were only reported in patients undergoing AF ablation, including two patients with pericardial effusion, one of whom required surgical repair, and another patient who died after inadvertent entry into an undiagnosed atrioesophageal fistula from a previous procedure. Conclusion The superior approach is most frequent approach for performing EP procedures in the setting of obstructed IVC. Transhepatic approach is a feasible alternative, and may provide a “familiar approach” for transseptal access when it is required. Adjunctive use of long sheaths, intravascular echocardiography, electro‐anatomical mapping and remote magnetic navigation may be helpful, especially if there is associated complex CHD. With careful planning, EP procedures can usually be successfully performed with a low risk of complications.

Radiofrequency ablation of persistent atrial fibrillation in a patient with situs inversus totalis and interrupted inferior vena cava

“…Obtaining adequate transseptal assess is essential to perform a left‐sided ablation. The same systemic review reported that the superior approach from SVC was the most frequently used strategy (52%), followed by inferior approach via the azygos or hemiazygos vein (24%), transhepatic approach (14%), and retroaortic approach (10%) 5 . In our patient, childhood surgical ASD repair surgery further complicated the transseptal attempts.…”

“…The same systemic review reported that the superior approach from SVC was the most frequently used strategy (52%), followed by inferior approach via the azygos or hemiazygos vein (24%), transhepatic approach (14%), and retroaortic approach (10%). 5 In our patient, childhood surgical ASD repair surgery further complicated the transseptal attempts. The superior approach from the LIJ vein was our choice with TEE guidance (esophageal posterior location with relatively standard views) instead of ICE (left-sided Azygous position visualizing dextrocardic chambers).…”

“…A recent systemic review that studied 143 EP procedures performed in patients with interrupted IVC found that IVC obstruction was not known before the index procedure in 54% of patients. 5 Very limited evidence is reported on how ablation can be performed in patients with situs inversus totalis and interrupted IVC.…”

“…In our case, although dextrocardia and the atretic course of IVC were known before the procedure, the presence of an inferior venous system draining into the left‐sided azygous vein and SVC was not delineated. A recent systemic review that studied 143 EP procedures performed in patients with interrupted IVC found that IVC obstruction was not known before the index procedure in 54% of patients 5 …”

Troubleshooting the challenges of transfemoral catheter ablation of atrioventricular nodal reentrant tachycardia in a patient with congenital interrupted inferior vena cava with azygos continuation

“…4 , 5 , 6 , 7 , 8 , 9 It is important for proceduralists to be aware that in such instances, less-than-favorable alternatives including superior (SVC and brachial) and transhepatic approaches should also be anticipated. 10 , 11 Superior approaches via the SVC and basilic veins have successfully been used in such instances and are preferred by many experienced operators. However, in the setting of a transfemoral approach, the utilization of longer sheaths allows for better navigation and maneuverability of the catheters.…”