Percutaneous transhepatic approach for cryoballoon pulmonary vein isolation in a patient with persistent atrial fibrillation and interruption of the inferior vena cava

Abstract

Pulmonary vein isolation (PVI) with Arctic Front cryoballoon has been an effective treatment for paroxysmal atrial fibrillation.1 The recent 2016 European Society of Cardiology guidelines and Heart Rhythm Society Guideline on the management of atrial fibrillation have established PVI as a cornerstone catheter ablation strategy during the primary index ablation for patients with symptomatic and drug-refractory atrial fibrillation.2 Furthermore, these guidelines recognized that cryoballoon catheter ablation can be an effective alternative to the traditional radiofrequency ablation catheters that have been historically used.2 The performance of PVI is typically achieved via the inferior vena cava (IVC) through the access of the femoral veins; however, congenital anomalies or venous occlusion may inhibit the use of this approach. In these rare circumstances, access to the cardiac chambers may be achieved via the superior vena cava or via retrograde aortic approaches. Unfortunately, these approaches are less favorable owing to reduced catheter control, manipulation, and stability.3, 4, 5 The purpose of this case report is to illustrate the safety and efficacy of performing PVI with the Arctic Front cryoballoon catheter via the transhepatic approach among patients with congenital anomalies. Access to the right atrium via the percutaneous transhepatic approach is an alternative method when traditional means are not feasible. The percutaneous transhepatic approach has been shown to be effective, with a complication rate of <5%.6 Although percutaneous transhepatic approach in performing cardiac ablation procedures is traditionally utilized in pediatric cases,6, 7, 8, 9 there is limited data on the transhepatic approach in the adult population.3