Clin Res Cardiol (2022). https://doi.org/10.1007/s00392-022-02002-5

Novel Approach: Successful Isolation of Persistent Left Supra Vena Cava with Pulsed Field Ablation.

S. Tohoku1, B. Schmidt2, S. Bordignon3, S. Chen1, L. Urbanek4, F. Pansera1, K. R. J. Chun1, for the study group: no

1Medizinische Klinik III - CCB, Agaplesion Markus Krankenhaus, Frankfurt am Main; 2Agaplesion Markus Krankenhaus, Frankfurt am Main; 3Medizinisches Versorgungszentrum, CCB am AGAPLESION BETHANIEN KRANKENHAUS, Frankfurt am Main; 4Station 24b Intensivstation, Agaplesion Markus Krankenhaus, Frankfurt am Main;

Introduction Persistent left supra vena cava (PLSVC) is one of the most common thoracal venous anomalies in adult cardiac malformations irrespective of congenital malfunction. The higher incidence of arrhythmicity from the PLSVC has been reported especially in patients with atrial fibrillation (AF), which indicates that electrical isolation of PLSVC is one of the important targets in AF ablation. However, the optimal approach for PLSVC isolation has remained unclear due to the potential risk of complications. Pulsed field ablation (PFA) is a new method of myocardial specific ablation by applying electrical oscillatory waves to cells and causing pores leading to disrupting cell membranes. Energy is delivered specifically to the myocardium without damaging nearby non-myocardial tissues. The first approved ablation device for PFA (FARAWAVETM) consists of a 12-Fr catheter with five splines carrying each four electrodes that is navigated over-the-wire via a steerable sheath. The shape of catheter can be changed according to the targeted anatomy. The combined concepts of PFA and the catheter form might be an applicable approach for PLSV ablation. Herein, we report two cases of successful electrical isolation of PLSVC with PFA. Case 1: A 73-year-old male patient was admitted to our hospital to undergo AF ablation. A transesophageal echocardiogram excluded structural heart disease and showed a dilated ostium of coronary sinus, patent foramen ovale of 5mm, and atresia of the right superior vena cava which indicated a PLSVC. The procedure was planned with a 3D mapping system guidance. After an angiography of PLSVC, the strategy was switched to PFA using FARAWAVE with a single transseptal approach because of the difficult transseptal puncture. After successful isolation of all four pulmonary veins (PVs), frequent extra systole beats with earliest activation site at the PLSVC were observed. A total of 4 applications were delivered with the FARAWAVE catheter in the star-fish-like form from the proximal to distal PLSVC. The last application on the level between left superior and inferior PVs eliminated the electric potential of PLSVC successfully. A 3D voltage map was delineated at the end of procedure. Case 2: A 78-year-old female patient with previously diagnosed sick-sinus-syndrome type Ⅲ was admitted for worsening palpitation. Catheter ablation was indicated after excluding other structural heart disease. A transesophageal echocardiogram showed a dilated ostium of coronary sinus and a common ostium of lateral PVs. The procedure was started with a selective angiography of PVs and PLSVC under fluoroscopic guidance with the FARAWAVE catheter. Frequent extra systole beats with earliest activation site at the PLSVC were observed even after the successful isolation of all four PVs. A total of 3 applications were delivered in the star-fish-like pose at the proximal, middle and distal PLSVC. The last application at the level of left common PV eliminated the electric potential of PLSVC successfully. Conclusions We reported two cases of successful PLSVC isolation in patients with AF using the FARAWAVE PFA catheter. Electrical isolation of large LPSVC at different levels using PFA appears to be feasible without observing signs of phrenic nerve palsy or atrio-ventricular node conduction disorders. Myocardial tissue specificity using PFA can be a safe approach to PLSVC ablation.

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