Successful left-sided accessory pathway ablation without reference catheter in patient with atresia of coronary sinus and thin persistent left superior vena cava

doi:10.4236/crcm.2013.28116

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Vol.2, No.8, 445-447 (2013) Case Reports in Clinical Medicine

http://dx.doi.org/10.4236/crcm.2013.28116

Successful left-sided accessory pathway ablation

without reference catheter in patient with atresia of

coronary sinus and thin persistent left superior

vena cava*

Qingxing Chen, Ye Xu, Kuang Cheng, Wenqing Zhu#

Department of Cardiology, Zhongshan Hospital, The Shanghai Institute of Cardiovascular Diseases, Fudan University, Shanghai,

China; #Corresponding Author: [email protected]

Received 7 September 2013; revised 1 October 2013; accepted 29 October 2013

which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

We report a case of atrioventricular reentrant

tachycardia (AVRT) with ostial atresia of the

coronary sinus (CS). Without the anatomic an-

giography, radiofrequency (RF) energy was ap-

plied at the mitral valve annulus and the bypass

tract was eliminated. After the therapy proce-

dure, by CS angiography, we knew the persis-

tent left superior vena cava (PLSVC), and the

coronary sinus was connected with vena cava

superior, very thin in a diameter. The therapy

procedure was successful. The patient has re-

mained completely symptom free.

Keyw ords: Ablation; Accessory Pathway; Atresia of

the Coronary Sinus

1. INTRODUCTION

Coronary sinus (CS) atresia is a rare cardiac anatomic

variant which causes failure to cannulate CS and consid-

erable challenges in affecting cure. CS ostial atresia was

associated with a few persistent left superior vena cavas

(PLSVC), an unroofed coronary sinus, or was a postop-

erative complication [1-5]. Patients with CS ostial atresia

have been reported to have atrioventricular reentrant

tachycardia [3-5], atrial flutter [4], and atrioventricular

nodal reentrant tachycardia [6].

We report a case of CS ostial atresia with anomalous

venous drainage into PLSVC with a left-sided accessory

pathway (AP) that was successfully eliminated by cathe-

ter ablation.

2. CASE REPORT

A 57-year-old man with recurrent paroxysmal su-

praventricular tachycardia (PSVT) effective to propa-

fenone was referred to our hospital for a cardiac electro-

physiologicstudy (EPS) and ablation one month ago. A

12-lead electrocardiogram (ECG) done during sinus

rhythm exhibited no delta waves. A 12-lead ECG done

during the palpitation revealed a regular, narrow QRS

tachycardia at a rate of 170 bpm with P’-waves in leads

II and aVF, QRS-P’ interval was 86ms; this suggested

that the patient had an atrioventricular reentrant tachy-

cardia (AVRT) through a concealed accessory pathway

(AP). The physical examination, chest x-ray, echocar-

diograms and serological examinations were normal.

After written informed consent was obtained from the

patient, EPS was done after the withdrawal of all antiar-

rhythmic drugs for five elimination half-lives.

One quadripolar electrode catheter was cannulated

from Vena cava inferior, positioned in the right ventricu-

lar apex. One multipolar electrode catheter was cannu-

lated from Subclavian Vein. Attempts to cannulate the

coronary sinus (CS) were unsuccessful. Without CS an-

giography, we set a proximal electrode of multipolar

catheter on the ostial of CS.

Baseline intervals during sinus were as follows: sinus

cycle length 660 ms, atrial His (AH) interval 79 ms, and

His-ventricular (HV) interval 64 ms. There was no ven-

tricular preexcitation during sinus rhythm and decre-

mental ventricular pacing down to 350 ms. A regular,

narrow QRS tachycardia with a cycle length of 350 ms

was repeatly induced. During tachycardia, proximal mul-

tipolar electrode was revealed V-A interval 86 ms, mid-

dle electrode was revealed V-A interval 145 ms, distal

*Conflict of Interest: None.

Q. X. Chen et al. / Case Reports in Clinical Medicine 2 (2013) 445-447

446

electrode couldn’t recorded ventricular potential. Ven-

tricular-atrial transmits are at the same rhythm. This sug-

gested the tachycardia was orthodromic atrioventricular

reentrant tachycardia (OAVRT) with a concealed left-

sided AP.

Mapping of the mitral valve annulus was performed

during ventricular pacing, using a Medtronic ablation

catheter with a 4-mm distal tip that was inserted from the

right femoral artery. The earliest activated point on atrial

side was recorded in the 3 o’clock region of the mitral

annulus. Radiofrequency (RF) energy, delivered to this

site for 240 seconds at a temperature of 60˚C, eliminated

the bypass tract. Fifteen minutes after the delivery of the

RF energy, there was persistent ventricularatrial (VA)

dissociation. At present, the patient had remained com-

pletely symptom-free.

CS angiography was done after the RF. It revealed that

ostium atresia of CS and CS was connected with anoma-

lous venous drainage into persistent left superior vena

cavas (PLSVC), very thin i n diameter (Figure 1).

3. DISCUSSION

We performed a catheter ablation of a left-sided AV

bypass tract in a patient with ostial atresia of CS. The

previously reported cases of CS ostial atresia were asso-

ciated with a few persistent left superior vena cavas

(PLSV C), an unroofed CS, or were a posto perative com-

plication [1-5]. Patients with CS ostial atresia have been

repor ted to have AVRT[3-5], atrial flutter [4] and atrioven-

tricular nodal reentrant tachycardia (AVNRT) [6]. In all the

reported cases, we found that left-sided AP is in the major-

ity.

The recognition of this anomaly is important for at

least two re asons. First, i t might prevent fu tile attemp ts

to access the CS conventionally which might lead to

prolonged x-ray exposure and serious complications

such as cardiac perforation. If the patient was suffering

from the AVNRT, lesion of slow pathway region would

be familiar. Second, in the presence of this anomaly,

particularly the PLSVC may be arrhythmogenic due to

its intricate relation with the ligament of Marshall and

a dilated CS [7]. Both conditions are known to favor

arrhythmogenesis. So, in our patients, recording poten-

tial or pacing mapping from the PLSVC or CS was

important. After the ablation, the PLSVC and CS were

cannulated, and extraordinary potential has not been

recorded.

Cathe ter ab la t ion o f a le f t fr ee -wal l A P is usuall y p er-

formed under the guidance of a reference electrode,

though ablation without a reference catheter has been

reported in a few experienced centers [8,9]. In our pa-

tient, the placement of a multipolar electrode catheter

only revealed the position of the ostial of CS. By endo-

cardial mapping of the multipolar electrode, we knew

the AVRT came of a left-sided AP. Without a reference

catheter, mapping of the mitral valve annulus couldn’t

be accurate. So, experience of the operator was more

important.

Figure 1. Coronary angiography after successfully ablation. (Left) Ablation catheter had been evacuated. Distal electrode of multi-

polar catheter was positioned on the ostial of the coronary sinus (CS). Coronary angiography showed ostium atresia of coronary

sinus (CS). (Right) coronary sinus (CS) was connect with anomalous venous drainage into left-persistent vena cava superior

(L-PVCS), very thin in diameter.

Q. X. Chen et al. / Case Reports in Clinical Medicine 2 (2013) 445-447 447

In conclusion, we report a case of CS ostial atresia

with anomalous venous drainage into PLSVC with a

left-sided AP that was successfully eliminated by catheter

ablation.

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