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. 2023 Feb 23;12(5):1783.
doi: 10.3390/jcm12051783.

Provocation and Localization of Arrhythmogenic Triggers from Persistent Left Superior Vena Cava in Patients with Atrial Fibrillation

Kentaro Minami  1 , Kohki Nakamura  2 , Eiko Maeno  1 , Keitaro Iida  1 , Ikuta Saito  1 , Taiki Masuyama  1 , Yoshiyuki Kitagawa  1 , Toshiaki Nakajima  1 , Yosuke Nakatani  2 , Shigeto Naito  2 , Shigeru Toyoda  1 , Milan Chovanec  3 , Jan Petrů  3 , Jan Škoda  3 , Koji Kumagai  4 , Petr Neužil  3
Affiliations

Provocation and Localization of Arrhythmogenic Triggers from Persistent Left Superior Vena Cava in Patients with Atrial Fibrillation

Kentaro Minami et al. J Clin Med. .

Abstract

Background: Although pulmonary vein isolation (PVI) is an established procedure for atrial fibrillation (AF), non-PV foci play a crucial role in AF recurrence. Persistent left superior vena cava (PLSVC) has been reported as critical non-PV foci. However, the effectiveness of provocation of AF triggers from PLSVC remains unclear. This study was designed to validate the usefulness of provoking AF triggers from PLSVC.

Methods: This multicenter retrospective study included 37 patients with AF and PLSVC. To provoke triggers, AF was cardioverted, and re-initiation of AF was monitored under high-dose isoproterenol infusion. The patients were divided into two groups: those whose PLSVC had arrhythmogenic triggers initiating AF (Group A) and those whose PLSVC did not have triggers (Group B). Group A underwent isolation of PLSVC after PVI. Group B received PVI only.

Results: Group A had 14 patients, whereas Group B had 23 patients. After a 3-year follow-up, no difference in the success rate for maintaining sinus rhythm was observed between the two groups. Group A was significantly younger and had lower CHADS2-VASc scores than Group B.

Conclusions: The provocation of arrhythmogenic triggers from PLSVC was effective for the ablation strategy. PLSVC electrical isolation would not be necessary if arrhythmogenic triggers are not provoked.

Keywords: atrial fibrillation; catheter ablation; persistent left superior vena cava.

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Conflict of interest statement

All authors declare that they have no conflict of interest.

Figures

Figure 1
Figure 1
Diagram Flow Showing Patient Treatments and Procedures. PLSVC, persistent left vena cava; PVI, pulmonary vein isolation.
Figure 2
Figure 2
Intracardiac echocardiographic views. (A): Duodecapolar catheter inside the PLSVC from dilated CS. (B): View of the PLSVC after the transseptal puncture. CS, coronary sinus; LA, left atrium; RA, right atrium; PLSVC, persistent left superior vena cava.
Figure 3
Figure 3
Fluoroscopic images and computed tomography. (A): Coronary sinus venography performed with a long sheath placed within the dilated coronary sinus (LAO view). * Circular mapping catheter placed in the left inferior pulmonary vein † Circular mapping catheter placed in the PLSVC. (B): Preprocedural CT imaging. anteroposterior view. (C): Posteroanterior view. CS, coronary sinus; PLSVC, persistent left vena cava; LAO, left anterior oblique; SVC, superior vena cava; LA, left atrium; RA, right atrium; CT, computed tomography.
Figure 4
Figure 4
Arrhythmogenic trigger from PLSVC. (A): The circular mapping catheters are positioned within the LIPV and PLSVC. During the first two sinus beats, the two components (left atrial far-field and PLSVC potential) are fused. During the ectopic rhythm (the third beat), the sharp potential of the PLSVC precedes the surface ECG by 60 ms. The atrial activation sequence is from distal to proximal on the CS during the PAC. (B): During AF initiation, the sharp potential of the PLSVC precedes the PAC, and the PAC arising from the PLSVC initiates the AF. CS, coronary sinus; PLSVC, persistent left vena cava; LIPV, left inferior pulmonary vein; PAC, premature atrial contraction; AF, atrial fibrillation.
Figure 5
Figure 5
Kaplan-Meier Estimates of 3-Year Freedom from Atrial Arrhythmia Recurrence. The recurrence of atrial arrhythmia in both groups after the last ablation procedure is shown. The electrical isolation of PLSVC was determined based on the electrophysiological study for the provocation of arrhythmogenic triggers initiating AF. No significant difference in arrhythmia recurrence was observed between the two groups. PLSVC, persistent left superior vena cava; AF, atrial fibrillation.
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