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.

Keywords: electrophysiology; inferior vena cava obstruction; interrupted inferior vena cava; superior approach; transhepatic approach.

Figure 1

PRISMA flow chart: the systemic review procedure

Figure 2

Example of transhepatic approach for ablation of right mid‐septal accessory pathway in 25‐year‐old patient with IVC obstruction due to neonatal surgery. (A) Hepatic venogram performed via superior access. (B) Percutaneous needle access into hepatic vein. (C) Hepatic venogram performed. (D) Wire inserted into right atrium. (E) Cryoablation catheter placed in mid‐septal position—right anterior oblique (RAO) view. (F) Left anterior oblique (LAO) view. IVC, inferior vena cava

Figure 3

Example of superior approach in 60‐year‐old female patient with AV nodal re‐entrant tachycardia and interrupted IVC. Top panels show fluoroscopic views with Ablation catheter (arrow) with His and coronary sinus (CS) catheters. Top left panel—right anterior oblique (RAO) view; Top right panel—Left anterior oblique (LAO) view. Bottom panels show corresponding electro‐anatomical images with ablation site (red dot) and His and CS catheters. Bottom left panel—RAO view; Bottom right panel—LAO view. IVC, inferior vena cava

Figure 4

Example of inferior approach for ablation of typical right atrial flutter with the aid of a steerable sheath (arrows) inserted via azygous vein. Left panel—left anterior oblique (LAO). Right panel—right anterior oblique (RAO) views

Figure 5

Example of transseptal access via superior approach in 66‐year‐old female patient with atrial fibrillation, dilated cardiomyopathy and occluded iliac veins due to prior surgery. (A) SL0 sheath and Transseptal needle (BRK‐1; bent to 150°) introduced via right internal jugular vein. (B) TEE guidance of transseptal puncture. (C) Guidewire passed into left atrium and pulmonary vein. (D) Ablation performed with aid of steerable sheath. (E) Lesion set for pulmonary vein isolation projected on merged CT—anterior view. (F) posterior view. CT, computerized tomography; TEE, transesophageal echocardiography

Figure 6

Advantages and disadvantages of different approaches used in the setting of inferior vena cava obstruction (IVC). Note: the absence of hepatic IVC in the diagram. AZV, azygos vein; HV, hepatic vein; IJV, internal jugular vein; SCV, subclavian vein