It's a long way to the top! Congenital venous anomalies and left isomerism limiting atrial fibrillation transcatheter...

Area of Science:

• Cardiology
• Interventional Cardiology
• Vascular Anatomy

Background:

• Atrial fibrillation (AF) is a prevalent cardiac arrhythmia linked to significant mortality and morbidity.
• Catheter ablation is a key treatment for AF, improving patient outcomes.
• The standard approach involves transseptal access via lower limb venous routes.

Observation:

• A rare case of complex venous anomaly was identified in a patient with persistent AF.
• This anomaly included a left-sided inferior vena cava with azygos continuation to a persistent left superior vena cava.
• The anomalous vein drained into an enlarged coronary sinus.

Findings:

• Venous anomalies can impede standard transseptal access for AF catheter ablation.
• This case highlights the anatomical challenges posed by such anomalies.
• Successful ablation may require alternative strategies.

Implications:

• Patients with AF and complex venous anomalies may require non-standard interventional techniques.
• Alternative percutaneous access, thoracoscopic approaches, or "ablate and pace" may be necessary.
• Careful pre-procedural imaging is crucial for planning AF ablation in patients with venous anomalies.