PO-04-081 ISOLATION OF PERSISTENT LEFT SIDED SUPERIOR VENA CAVA USING PULSED FIELD ABLATION

Abstract

Pulmonary vein foci account for more than 90% of triggers for atrial fibrillation, most commonly treated with complete pulmonary vein isolation. Non–pulmonary vein triggers are the drivers of atrial fibrillation in a subgroup of patients. One such trigger is a persistent left superior vena cava (SVC), which may contain remnant muscular and pacemaker tissue carried over from embryonic life. However, reported complications of radiofrequency ablation of this structure are significant, including vein stenosis, tamponade and phrenic nerve injury. Pulsed field ablation is a promising new technology that may be uniquely suited to avoid such a complications. This case illustrates the first known application of pulsed field ablation of a left sided SVC. N/A The patient is a fifty-two year old male with a history of coronary artery disease and persistent atrial fibrillation refractory to medical therapy including rate and rhythm control strategies. He is status post multiple cardioversions with restoration to normal sinus rhythm for a relatively short period of time. The patient underwent an ablation procedure at which time it was discovered that he had an isolated persistent left sided SVC. Pulmonary vein isolation was performed using a combined radiofrequency and pulsed field ablation lattice tip catheter (Affera inc., Watertown, MA). Accordingly to study protocol, lesions were placed using radiofrequency anteriorly and pulsed field lesions posteriorly in the left atrium around the pulmonary veins resulting in complete isolation. The patient also developed a counterclockwise typical atrial flutter which was ablated. Given the propensity for triggers from the SVC, pulsed field ablation was performed by creating a circumferential lesion set superiorly beyond the left superior pulmonary vein region and inferiorly near the mid coronary sinus below the left inferior pulmonary vein. A linear lesion set connecting these two regions was also performed along the atrial portion of the coronary sinus, with subsequent confirmation of exit block and elimination of all local electrograms. In patients with persistent left SVC, pulsed field ablation is feasible without the risk of phrenic nerve injury or tamponade from excessive contact force. Further studies are necessary to examine whether the complications associated with LSVC isolation can be minimized.