Transseptal puncture from the jugular vein and balloon cryoablation for atrial fibrillation in a patient with azygos continuation of an interrupted inferior vena cava.
OBJECTIVE
Inferior vena cava (IVC) interruption is a rare anatomic variant where the azygos vein (AV) drains the blood from the IVC to the upper part of the right atrium via the superior vena cava. Here, we report balloon cryoablation of the pulmonary veins (PVs) via superior access in a patient with atrial fibrillation.


RESULTS
After the first failed ablation attempt due to IVC interruption, balloon cryoablation with a 28-mm Arctic Front Advance cryoballoon (Medtronic CryoCath LP, Quebec, Canada) via superior access was performed; it requires only a single transseptal puncture (TP), and the patient had optimal PV anatomy. Deflectable electrodes were inserted into the right ventricle and coronary sinus from the right femoral vein. The right internal jugular vein was accessed using an SL0 transseptal sheath and BRK needle. The TP was performed under transoesophageal echocardiographic guidance with a Safe Sept wire because the septum was stiff. All PVs were engaged: the left using an ablation catheter before balloon insertion and the inferior following a 'push-up' technique because of a leak above the veins. Cryothermal energy was delivered after checking for occlusion. The procedure lasted 210 min, fluoroscopy time was 78 min, and air-kerma dose was 194 mGy. During the 6-month follow-up, no episodes of atrial fibrillation were detected on several Holter recordings.


CONCLUSIONS
Successful PV isolation in patients with AV continuation of an interrupted IVC can be safely performed using superior access with balloon cryoablation, after several modifications of standard equipment.
2nd Department of Cardiology, Poznań University of Medical Sciences, ul. 28 Czerwca 1956roku No 194, Poznań 61-848, Poland abaszko@wp.pl.
Artur
A
Baszko
2nd Department of Cardiology, Poznań University of Medical Sciences, ul. 28 Czerwca 1956roku No 194, Poznań 61-848, Poland.
Piotr
P
Kałmucki
2nd Department of Cardiology, Poznań University of Medical Sciences, ul. 28 Czerwca 1956roku No 194, Poznań 61-848, Poland.
Rafał
R
Dankowski
1st Department of Cardiology, Poznań University of Medical Sciences, Poznań, ul. Długa 1/2, Poznań 61-848, Poland.
Magdalena
M
Łanocha
2nd Department of Cardiology, Poznań University of Medical Sciences, ul. 28 Czerwca 1956roku No 194, Poznań 61-848, Poland.
Tomasz
T
Siminiak
2nd Department of Cardiology, Poznań University of Medical Sciences, ul. 28 Czerwca 1956roku No 194, Poznań 61-848, Poland.
Andrzej
A
Szyszka
D000368:Aged; D001281:Atrial Fibrillation / Q000601:surgery*; D001401:Azygos Vein / Q000002:abnormalities* / Q000601:surgery; D006328:Cardiac Catheterization / Q000379:methods; D003452:Cryosurgery / Q000379:methods*; D005260:Female; D006329:Heart Conduction System / Q000601:surgery*; D006801:Humans; D011667:Pulmonary Veins / Q000601:surgery*; D011677:Punctures / Q000379:methods; D016896:Treatment Outcome; D014682:Vena Cava, Inferior / Q000002:abnormalities* / Q000601:surgery
Atrial fibrillation; Azygos vein; Balloon cryoablation; Transseptal puncture