Atrium Junction Research Articles

Transcatheter stenting of superior vena cava to treat postoperative SVC syndrome in a child: a case report

BackgroundSuperior vena cava (SVC) obstruction leading to SVC syndrome is an uncommon but potential complication of cardiac surgeries that involve dissection and anastomosis around the great vein. We present a case of iatrogenic SVC obstruction that was initially treated with transcatheter balloon angioplasty, which provided temporary relief, and ultimately resolved by stenting the affected segment.Case presentationThe index case underwent total anomalous pulmonary venous connection (TAPVC) repair and presented 3 months after surgery with features of SVC obstruction. Initially, transcatheter balloon angioplasty was performed, providing relief from the obstruction; however, the condition recurred within one month. Finally, the patient was treated with percutaneous stenting of superior vena cava, through femoral venous route, using 8 mm × 30 mm balloon-expandable bare metal stent (Formula 418, Cook Medical, Bloomington, IN). Remarkable relief of obstruction was established with decrease in mean gradient across SVC–right atrium junction to 2 mm Hg (from 12 mm Hg before balloon angioplasty and 18 mm Hg before stenting).ConclusionPercutaneous treatment for iatrogenic SVC obstruction developing after cardiac surgery appears to be effective. Close monitoring is required in the postoperative period for early diagnosis and timely intervention.

Injury to the sinus nodal artery during radiofrequency ablation of atrial fibrillation and atrial tachycardia: its prevalence and treatment with percutaneous coronary intervention

Abstract Background/Introduction Injury to the sinus node artery (SNA) leading to SN dysfunction during radiofrequency catheter ablation (RFCA) of atrial Fibrillation (AF) and atrial tachycardia (AT) has been reported. Purpose The purpose of this study was to elucidate the prevalence and clinical course of SNA injuries during RFCA of AF/AT and examine the efficacy of the percutaneous coronary intervention (PCI) to restore SN function. Methods We retrospectively analyzed data from 6,906 consecutive patients (pts) who underwent RFCA of AF/AT (6,379 pts with AF ablation and 527 pts with AT ablation) in two institutions between January 2013 and December 2022. Results Among 6,906 pts, 9 (0.13%) pts developed SN dysfunction due to SNA injury during RFCA (8 with AF, 1 with AT). Acute SNA injury (total occlusion or severe narrowing of the SNA) was confirmed by coronary angiography (CAG) during the RFCA session in 8/9 pts. In the remaining patient, SNA injury was suspected based on the CT angiography. The culprit sites of the SNA injury were located at the septal site of the superior vena cava-right atrium junction in 4 pts (44%), on the left atrial appendage ridge in 3 (33%), on the roof of the left atrium adjacent to the right superior pulmonary vein in 1 (11%), and in the persistent left superior vena cava in 1 (11%). PCI to the occluded SNA was performed in 8 of the 9 pts: 1) coronary blood flow of the SNA was restored by a 0.014" guidewire advancement into the occluded artery using a micro-catheter followed by direct nitroprusside injection in 4 pts; 2) the direct balloon angioplasty using 0.75-1.5 mm diameter balloons was required to maintain the blood flow of SNA in 3 pts; and 3) CAG revealed spontaneous recovery of the blood flow of SNA in one pt. The remaining patient did not receive the CAG/PCI. All 8 pts who underwent the PCI resulted in restoration of normal sinus rhythm. During a median of 44 months follow-up, all 8 pts who received the PCI maintained normal sinus rhythm, while one patient without PCI demonstrated persistent SN dysfunction. Conclusions SNA injury during RFCA is a rare but critical complication. Prompt recognition by CAG and subsequent PCI effectively restores SN function in pts with unexpected SN dysfunction during RFCA procedures.

Successful catheter ablation of atrial tachycardia initiated with orthodromic capture of superior vena cava potentials.

Acase of successful catheter ablation of paroxysmal atrial fibrillation and atrial tachycardia is reported. After pulmonary vein isolation, atrial tachycardia was induced by the use of isoproterenol and burst pacing from the catheter in the right atrium. An attempt was made to create athree-dimensional (3D) map of the atrial tachycardia, but the atrial tachycardia was terminated in the middle of the mapping. The 3D map was insufficient but indicated that the superior vena cava was involved in the circuit. When the intracardiac electrograms were reviewed, it was found that the atrial tachycardia was initiated with orthodromic capture of superior vena cava potentials and it was considered that the atrial tachycardia involved the superior vena cava-right atrium junction. Accordingly, superior vena cava isolation was performed. After that, atrial fibrillation and atrial tachycardias were not induced by the use of isoproterenol and burst pacing. In this case, an intracardiac electrogram at the time of induction of the tachycardia was helpful for understanding the circuit of the tachycardia.

Extracardiac Pericardial Conduit Repair: A Novel Approach to Complex Scimitar Syndrome with Dextrocardia and intact Inter-Atrial Septum

Scimitar syndrome (SS) has been repaired using different surgical procedures like intracardiac baffle and redirection (directly or by using synthetic grafts) of the scimitar vein to the right or left atrium. However, several accompanying anatomic abnormalities make these interventions difficult. The most common variations complicating reimplantation of the scimitar vein (SV) include dextrocardia, hypoplasia of the right pulmonary artery and lung sequestration. Here, we present a novel method for extracardiac repair of SS with dextrocardia and intact atrial septum in which the right superior and inferior pulmonary veins formed a common venous chamber at the diaphragmatic surface and opening at the right atrium (RA) and inferior vena cava (IVC) junction. Although the use of pericardial tube grafts is seen in literature before, its use for rerouting a complex venous complex into left atrium is first reported in this case.

Reliability of intra-atrial ECG method of insertion of central venous line through right internal jugular vein when compared to formula and radiological landmark method: a prospective randomized study

BackgroundIdeal position of central venous catheter tip should be within 2 cm above and 1 cm below superior vena cava–right atrium (SVC-RA) junction. The objective of the study was to compare intra-atrial ECG method of Central venous catheterization of right internal jugular vein (IJV) with traditional methods. A prospective randomized trial enrolling 90 patients were alternatively allocated to three groups and comparison of intra-atrial electrocardiography, radiological landmark and Pere’s formula method for correct positioning of central venous catheter tip were done and tip position were confirmed with post-procedural TEE (transesophageal echocardiography).ResultsCatheter tip was present at the ideal position in 100% cases in intra-atrial ECG method compared to only 23.4% in formula method and 93.3% in landmark method (p value 0.001). In intra-atrial method group, the central venous catheter tip was placed perfectly in all patients, position of the catheter tip was not acceptable in 71.4% of the patients where formula method is used and not acceptable in 11.1% when landmark method is used (p value 0.001). However, we did not encounter any catheter related complications in any of these groups.ConclusionsIntra-atrial ECG method carries the advantage of ideal positioning of the central venous catheter tip by right IJV route in almost all cases when compared to conventional formula and landmark method to some extent. Also, immediate confirmation and real time verification of central venous catheter (CVC) tip is possible, thereby avoids the need for post-procedural chest X-ray and other methods of central venous placement confirmation like arterial blood gas analysis etc., Hence, intra-atrial ECG method is cost effective and safer for confirmation of CVC tip in all the situations.

CARD21: The Effect of Drainage Cannula Design and Tip Position on Thrombosis Risk During Venoarterial Extracorporeal Membrane Oxygenation: A Computational Analysis

Background: Venoarterial extracorporeal membrane oxygenation (VA ECMO) supports critically ill patients with refractory cardiopulmonary failure. Drainage cannulae remove venous blood from the patient, but variability in cannula selection and tip position may impact flow dynamics and thrombosis risk. Therefore, this study investigated the effect of tip position of single-stage (SS) and multi-stage (MS) VA ECMO drainage cannulae on the risk of thrombosis. Methods: Computational fluid dynamics was used to model flow dynamics within a patient-specific geometry of the venae cavae. The tip of the SS and MS cannulae was modelled in the superior vena cava (SVC), SVC-Right atrium (RA) junction, mid-RA, inferior vena cava (IVC)-RA junction, and IVC. Constant mass flow rates were applied at all major vein inlets reflecting normal physiological flows. Drainage flow rates of the cannula were set at a constant 4 L/min throughout all simulations. The risk of thrombosis was assessed by measuring blood residence time, stagnant volume, rate of blood washout, and high wall shear stress. Results: Changes in the tip position of the SS cannula resulted in variability of thrombosis risk, whereas the MS cannula showed similar thrombosis risk during all simulations. The SS cannula showed reduced thrombosis risk arising from stagnant regions when placed in the SVC or SVC-RA junction, whereas an MS cannula was predicted to create stagnant regions during all tip positions (Figure 1). Conversely, the risk of thrombosis was increased in all positions with the SS cannula arising from higher maximum wall shear stresses (Table 1). When positioned in the IVC-RA junction and IVC, the SS cannula exhibited higher risk of thrombosis arising due to both high and low shear, compared to the MS cannula. Conclusion: Tip position of the drainage cannula impacts cannula flow dynamics and, subsequently, the risk of thrombosis. The use of MS cannulae can reduce high shear-related thrombosis, but SS cannulae can eliminate stagnant regions when advanced into the SVC. Therefore, the choice of cannula design and tip position should be carefully considered during cannulation.Figure 1. Comparison of stagnation regions between the single-stage (a) and multi-stage (b) cannulae at varying tip positions.

Totally Endoscopic Surgery for Repairing Sinus Venosus Atrial Septal Defect Using Double-Patch Technique on Beating Heart.

Minimally invasive cardiac surgery has not been widely applied in repairing sinus venosus atrial septal defect (SV-ASD). Most were minithoracotomy using the single-patch technique for patients with anomalous pulmonary veins (APVs) connecting to the superior vena cava-right atrium (SVC-RA) junction. It is unclear whether patients with APVs draining high to the SVC can be repaired safely and effectively through port access. From May 2019 to October 2022, 11 consecutive SV-ASD patients with APVs connecting high to the SVC were enrolled in this prospective study. One 12 mm port and 2 trocars (5.5 mm and 10 mm) were established. The pleural and pericardial spaces were filled with CO2. The SVC was snared just below the azygos vein. The RA incision was longitudinally extended along the SVC-RA junction to the SVC. The bovine pericardial patches were used to redirect the APV flow to the left atrium through the ASD and to enlarge the SVC and the SVC-RA junction. There were no early or late deaths and no reoperations. The concomitant procedures included 5 patients (45.5%) with patent foramen ovale closure, 2 with ASD extension, and 3 with tricuspid valve repair. No endoscopic failure was recorded. The average cardiopulmonary bypass and operative times were 96 (23) min and 190 (30) min, respectively. No cases of venous stenosis or sinus node dysfunction were noted during follow-up of 16.4 ± 12.2 months. SV-ASD with the APVs draining high to the SVC could be repaired safely and effectively through port access with a double-patch technique.

An unusual cause of chest pain.

A 78-year-old female with a history of lymphoma presented to the emergency department (ED) because of chest discomfort. A chest x-ray was performed and revealed the diagnosis. As shown in Figure 1, the patient's Port-A-Cath fractured and part of it was displaced to the right heart (Figures 1 and 2). The discontinuity was noted at the level of the left first rib and clavicle. The mid and distal portion migrated and was seen within the distal superior vena cava, right atrium, and possibly projecting into the right ventricle. The decision was made to admit the patient to conduct endovascular retrieval. One of the rare complications of a Port-A-Cath placement is its fracture and displacement into the heart. The most common site of displacement is at the superior vena cava-right atrium junction, and it can further embolize into the right ventricle.1 This complication is rare, with a reported incidence of 0.4%–1.8% and 66% of patients developing the fracture within 1 year.2 Some causes that might lead to a port fracture and displacement include the type of port used, the site of placement, and the duration of catheter use.2 An endovascular approach is used to retrieve the fractured catheter.3 Knowledge of this complication can help emergency physicians when evaluating a post-chemotherapy patient because catching it early can prevent fatal complications such as cardiac arrhythmias and septic embolization.3

The effect of drainage cannula tip position on risk of thrombosis during venoarterial extracorporeal membrane oxygenation

Background and objectivesVenoarterial extracorporeal membrane oxygenation (VA ECMO) is able to support critically ill patients undergoing refractory cardiopulmonary failure. It relies on drainage cannulae to extract venous blood from the patient, but cannula features and tip position may impact flow dynamics and thrombosis risk. Therefore, this study aimed to investigate the effect of tip position of single-stage (SS) and multi-stage (MS) VA ECMO drainage cannulae on the risk of thrombosis. MethodsComputational fluid dynamics was used to model flow dynamics within patient-specific geometry of the venous vasculature. The tip of the SS and MS cannula was placed in the superior vena cava (SVC), SVC-Right atrium (RA) junction, mid-RA, inferior vena cava (IVC)-RA junction, and IVC. The risk of thrombosis was assessed by measuring several factors. Blood residence time was measured via an Eulerian approach through the use of a scalar source term. Regions of stagnant volume were recognised by identifying regions of low fluid velocity and shear rate. Rate of blood washout was calculated by patching the domain with a scalar value and measuring the rate of fluid displacement. Lastly, wall shear stress values were determined to provide a qualitative understanding of potential blood trauma. ResultsThrombosis risk varied substantially with position changes of the SS cannula, which was less evident with the MS cannula. The SS cannula showed reduced thrombosis risk arising from stagnant regions when placed in the SVC or SVC-RA junction, whereas an MS cannula was predicted to create stagnant regions during all tip positions. When positioned in the IVC-RA junction or IVC, the risk of thrombosis was higher in the SS cannula than in the MS cannula due to both high and low shear flow. ConclusionTip position of the drainage cannula impacts cannula flow dynamics and, subsequently, the risk of thrombosis. The use of MS cannulae can reduce high shear-related thrombosis, but SS cannulae can eliminate stagnant regions when advanced into the SVC. Therefore, the choice of cannula design and tip position should be carefully considered during cannulation.

Surgical Management of Cardiac Masses in Right Atrium Among Bone Sarcoma Pediatric Patients With Totally Implanted Ports.

IntroductionTotally implanted ports (PORTs) have been widely used among patients with malignancy. Cardiac metastasis secondary to bone sarcoma and catheter-related right atrial thrombosis (CRAT) can be both present as cardiac masses. However, these two cardiac masses share very similar imaging characteristics.MethodsThe features, treatments, and outcomes of 5 bone sarcoma pediatric patients with PORTs who suffered from cardiac masses in the right atrium were analyzed. Clinical data and histological characteristics of cardiac masses were also recorded.ResultsAmong 928 patients with malignancy and PORTs, 5 bone sarcoma pediatric patients were found to have cardiac masses in the right atrium. The catheter tips were located in the right atrium of 4 patients and the superior vena cava-right atrium junction (CAJ) of 1 patient. Four patients with good response to anti-tumor treatment had received surgical lumpectomies for pathologic identification and mass excision, with cardiac metastases among 1 patient and thromboses among 3 patients. The median time from venous access port implantation to cardiac mass detection for CRAT was 6.3 months (range: 4.7–6.8 months) and to diagnosis of or possible cardiac metastasis was 13.3 months (range: 11.2–15.4 months).ConclusionThe placement of a catheter tip into the right atrium should be avoided. The time from PORTs implantation to cardiac mass detection might serve as a potential tool to differentiate cardiac metastasis from CRAT. Surgical management may be an effective treatment for bone sarcoma pediatric patients who had good response to anti-tumor treatment and suffered from cardiac masses in the right atrium.

Feasibility of a novel algorithm for automated reconstruction of the left atrial anatomy based on intracardiac echocardiography

Abstract Funding Acknowledgements Type of funding sources: None. Background Intracardiac echocardiography (ICE) is frequently used to guide electrophysiology procedures. The novel pre-commercial automated algorithm is a model-based algorithm, developed using machine learning methodology, which reconstructs a 3D anatomy of the left atrium (LA) and its structures based on a set of 2D ultrasound (US) frames, without the need to manually annotate US contours. Potential advantages are shortening of mapping time and better anatomy resolution when compared to conventional anatomical mapping techniques. Purpose Determine the early feasibility of the automated LA anatomy algorithm in routine clinical setting. Methods We included 16 patients (64±9 years, 88% males, body mass index 27±3, parasternal long axis LA diameter 40±3mm) undergoing LA mapping/catheter ablation (conscious sedation in 56% and general anaesthesia in the remaining cases). 2D US frames were acquired from three ICE-positions: superior vena cava/high right atrium (RA) junction, RA and right ventricular outflow tract. The automated LA anatomy map was validated in two steps: 1) identification of anatomical structures (pulmonary veins [PV] and left atrial appendage) by alignment of the ablation catheter to the automated map; and 2) assessment of PV anatomical accuracy by analysing the relationship with the automated lesion tags (3mm lesion radius, 3mm for 8sec stability criteria and 5-20g average contact force) and the PV antrum of the automated map in 9 patients with paroxysmal atrial fibrillation undergoing first time point-by-point radiofrequency PV isolation (PVI). In step 2, PV pairs were divided into 6 segments (total of 12 segments per patient) and were classified as accurate, insufficient ("floating" lesion tags), or excessive anatomy (invisible lesion tags). Results Mean 2D US frames per patient was 29±6 and acquisition time was 16±4 min. In the step 1 validation, all anatomical structures were correctly identified in the 16 patients by the automated algorithm. The step 2 validation showed anatomical accuracy in 76% of all 108 PV segments analysed. There was a range of 0-2 and 0-5 of the total 12 segments per patient with insufficient and excessive anatomy, respectively. In all cases with PV segment anatomical discrepancy, this was corrected with standard anatomy collection with the ablation catheter in ≤2min. In the whole patient group, catheter ablation was successfully performed on the automated map without complications. Conclusions The automated ICE-based 3D LA map algorithm performed overall well and correctly identified the LA anatomical structures in all patients. Anatomical PV antrum accuracy was high, and the majority of PV segments needed no manual correction before proceeding to PVI.

Percutaneous Retrieval of Dislodged Chemo Port Catheter With Inaccessible Tips by a Simplified Technique

Central venous port catheters (CVPCs) are commonly employed for long-term chemotherapy. One of the rare complications associated with CVPCs is catheter fracture and further embolization of the fragmented segment into the heart. The most common site of embolization is the superior vena cava-right atrium (RA) junction. However, infrequently, the catheter may embolize further distally into the right ventricle (RV) and beyond making the fragmented tips difficult to access directly with a snare. Here, we report a case wherein both the catheter tips were lodged in the RV cavity forming a loop in the RA. This necessitated the use of a modified technique to retrieve the fragment percutaneously.

Late venous air embolism following insertion of Mayfield head pins.

Dear Editor, Venous air embolism (VAE) is not an uncommon event during neurosurgical procedures. It is an iatrogenic complication that occurs when air from the atmosphere enters into the systemic circulation specifically when the surgical site is above the level of heart producing a sub-atmospheric pressure in the open veins. A 27-year-old male diagnosed as a case of fronto-temporo-parietal meningioma was posted for craniotomy and excision under general anesthesia. His Glasgow Coma Scale [GCS] was 15, and no neurological deficit was present. All laboratory investigations were within normal limits. His magnetic resonance imaging was suggestive of large well-defined lesion in left Sylvian fissure, extending into left basal cistern with mass effect. Following anesthesia induction, a Mayfield pin was used to stabilize the head of the patient in a supine position. The pin was removed and reinserted by the surgeon to improve the surgical access. Half an hour later, the surgeon repositioned the patient with head end elevated by 30 degree. We observe a sudden fall in end-tidal carbon dioxide concentration [EtCO2] from 30 to 19 mmHg with a drop of oxygen saturation from 100% to 95%. Rest of the vital parameters including heart rate and blood pressure demonstrated no change from baseline. We started the management with administration of 100% oxygen and intravenous fluids. We could aspirate 4–5 ml of air through the central venous line catheter [Arrow triple lumen central venous catheter, 7 French sizes, and 16-centimeter length]. We confirmed the central venous line position with electrocardiogram as a guide. The superior vena cava – right atrium junction positioning of the central venous line was confirmed with a tall P wave, which was equal to R wave height. The time frame between the event and air aspiration was one and half minutes. Within 1–2 min of air aspiration, oxygen saturation returned back to normal and EtCO2 rose up to 25 mmHg from 19 mmHg. No further episodes of VAE occurred during surgery. Mayfield head pin is commonly used in neurosurgical patients to keep the head stable during surgery. The literature is scarce in case reports showing an association of VAE and Mayfield head pins in adult patients.[12] Ture H et al. observed that the rate and severity of VAE were significantly lower in patients with 30-degree head elevation than in patients with 45-degree head elevation undergoing craniotomy in semi-sitting position.[3] This was a case of late VAE during repositioning of patient possibly following air entrainment through diploic veins injured at first attempt of pin insertion. In our case, we could not find any other possible explanation for this sudden decrease in EtCO2 except for the traumatized initial skull pin site being culprit for air entrainment after a change in position. At this time point, the surgery was not started and anesthetic depth was well maintained. The proper scanning of the surgical site by a surgeon before pin insertion, avoidance of sudden change in patient positioning, and proper suturing of the initial traumatized pin insertion site could avert this iatrogenic complication. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Real use of a novel automatic motorized laser balloon for the ablation of atrial fibrillation

Abstract Background Electric isolation of the pulmonary veins (PVs) can successfully treat patients with atrial fibrillation (AF). Isolation of pulmonary veins can be achieved by several methods: radiofrequency, cryoballoon or laser balloon ablation (LBA). The main procedural challenge with either method is to achieve a continuous circumferential lesion at the left atrium-PVs junction, with the persistence of functional gaps. Purpose A novel endoscopic ablation system equipped with a precise motor control system (MCS) has been evaluated. The balloon is used with an endoscope to directly visualize and ablate tissue at the left atrial-PVs junction with laser energy. This system enables uninterrupted, high-speed, circumferential lesion creation under direct control of the physician. The MCS is intended to reduce procedure time and to ensure continuity of ablation lesions. The feasibility of the motorized ablation in terms of extent of applicability along each PV-left atrium junction and time of use of the manual point-by-point mode has been investigated. Methods 27 consecutive patients (male 70.3%, age 61.2±8.7 years) with paroxysmal or persistent AF who underwent LBA were enrolled in our institution. Exclusion criteria were any contraindication for the procedure including the presence of intracavitary thrombosis and contraindications to general anesthesia or deep sedation. After transseptal puncture, the balloon-based endoscopic ablation system was advanced to each PV ostium, and laser energy were projected onto the target. Results A total of 110 PVs were treated with LBA; in 9 patients there was a redundant right intermediate pulmonary vein; in 4 patients there was a right common ostium and in 2 a left common ostium. MCS was used for 82 PVs (74.5%): in particular, MCS was used continuously between 180° and 325° degrees (50 to 90% of PV circumference) for 35 PVs (31.8%) and between 326° and 359° degrees (91 to 99% of PV circumference) for 25 veins (22.7%). In 13 PVs (12%) MCS was used for the entire circumference. During 8508 (19.6%) seconds out of a total of 43.368 seconds, laser energy delivery occurred in the rapid mode by MCS. No clinical complications, either local or systemic (stroke or TIA, pericardial effusion, pericardial tamponade, pulmonary vein stenosis, esophageal injury, temporary or permanent phrenic nerve palsy), were observed neither during the use of MSC nor during the use of manual point-by-point mode. Of note, a pinhole rupture of the balloon occurred in 3 cases of our series, during the use of MCS, without harm to the patient and requiring only replacement of the LBA. Conclusions In our case series, laser balloon ablation with the help of motor control system appears safe and feasible in most cases for large portions of pulmonary vein circumference, providing considerable time sparing (74.5% of total ablation extent in 19.6% of total ablation time). Funding Acknowledgement Type of funding sources: None.

Location of sinoatrial artery and atria

Abstract Background Clinically manifested injury to the coronary arteries during catheter ablation procedures for atrial arrhythmias is rare. Injury to sinoatrial artery can cause sinus arrest and lead to permanent pacemaker implantation. Previous studies only described the anatomy of the artery but not the relation with atrium. Objective Our study aims to illustrate the course of the sinoatrial artery in relation to the atrium. Methods The images of coronary computed tomography angiography (CCTA) of 110 patients performed from June to September 2019 were reviewed. Results The sinus node was supplied by either single artery (98.18%) or dual blood supply (1.82%). Sinoatrial artery mostly originates from right coronary artery (56.25%), followed by left circumflex artery (42.85) and the aorta (0.90%). When sinoatrial artery originated from right coronary artery or the aorta, it ran medially to the right atrium which its course vertically lied within 0.35±0.51 cm above and 1.45±0.63 cm below the superior vena cava-right atrium junction. The artery then passed between left atrium and right atrium, which 21.88% of the course ran within 0.5 cm from the right upper pulmonary vein ostium. When sinoatrial artery arises from left circumflex artery, 95.83% of this pathing were anterior to left atrial appendage. Only 4.17% went along anteriorly to the left upper pulmonary vein. Most of sinoatrial artery that arises from left circumflex artery (97.92%) ran pass the upper one-third of left atrium, then ran toward posteroseptum of right atrium. This course vertically lied within 0.51±0.73 cm above and 0.67±0.83 cm below the superior vena cava-right atrium junction. Additionally, we found that 39.58% of sinoatrial artery arises from left circumflex artery course lied within 0.5 cm from right upper pulmonary vein ostium. Conclusion Exceeding precaution while performing radiofrequency ablation at anterior upper one-third left atrium, base of left atrium appendage, upper part septal wall of right atrium and right upper pulmonary vein ostium should be established to prevent sinoatrial artery injury. Funding Acknowledgement Type of funding sources: None.

A rare case of obstructive supracardiac TAPVR (Total Anomalous Pulmonary Venous Return) with aberrant right subclavian artery.

Congenital aortic arch malformations manifest a broad-spectrum of differences and abnormalities that come from disturbed embryogenesis of branchial arches. Current case was a 10 months old baby girl with length of 69 cm (less than –3 SD) and weight of 5.5 kg (less than –3 SD). The patient had history of recurrent lower respiratory tract infections since the time of birth and failure to gain adequate weight since the time of birth. The patient has been having multiple check-ups with registered medical practitioners in the nearby locality and multiple courses of antibiotics with only partial resolution of symptoms. The 2-D echocardiogram showed her to be a case of supracardiac type of “Total Anomalous Pulmonary Venous Return (TAPVR)”. All pulmonary veins making a confluence and draining into the right atrium. Significant turbulence observed at the level of superior vena cava to right atrium junction. A level of obstruction was recorded at the junction of the confluence of pulmonary veins and the vertical vein. There was aberrant right subclavian artery from the aortic arch as its third branch with no obstruction or aneurysm formation, having retrotracheal and esophageal course.

Real use of a novel automatic motorized laser balloon for the ablation of atrial fibrillation

Abstract Funding Acknowledgements Type of funding sources: None. Background Electric isolation of the pulmonary veins (PVs) can successfully treat patients with atrial fibrillation (AF). Isolation of pulmonary veins can be achieved by several methods: radiofrequency, cryoballoon or laser balloon ablation (LBA). The main procedural challenge with either method is to achieve a continuous circumferential lesion at the left atrium-PVs junction, with the persistence of functional gaps. Purpose A novel endoscopic ablation system equipped with a precise motor control system (MCS) has been evaluated. The balloon is used with an endoscope to directly visualize and ablate tissue at the left atrial-PVs junction with laser energy. This system enables uninterrupted, high-speed, circumferential lesion creation under direct control of the physician. The MCS is intended to reduce procedure time and to ensure continuity of ablation lesions. The feasibility of the motorized ablation in terms of extent of applicability along each PV-left atrium junction and time of use of the manual point-by-point mode has been investigated. Methods sixteen consecutive patients (male 68.7%, age 60.9 ± 7.8 years) with paroxysmal or persistent AF who underwent LBA were enrolled in our institution. Exclusion criteria were any contraindication for the procedure including the presence of intracavitary thrombosis and contraindications to general anesthesia or deep sedation. After transseptal puncture, the balloon-based endoscopic ablation system was advanced to each PV ostium, and laser energy were projected onto the target. Results A total of 62 PVs were treated with LBA; in 3 patients there was a redundant right intermediate pulmonary vein; in 4 patients there was a right common ostium and in one a left common ostium. MCS was used for 41 PVs (66.1%): in particular, MCS was used continuously between 180° and 325° degrees (50 to 90% of PV circumference) for 22 PVs (35.5%) and between 326° and 359° degrees (91 to 99% of PV circumference) for 16 veins (25.8%). In 3 PVs (4.8%) MCS was used for the entire circumference. During 5.659 (23.6%) seconds out of a total of 23.986 seconds, laser energy delivery occurred in the rapid mode by MCS. No clinical complications, either local or systemic (stroke or TIA, pericardial effusion, pericardial tamponade, pulmonary vein stenosis, esophageal injury, temporary or permanent phrenic nerve palsy), were observed neither during the use of MSC nor during the use of manual point-by-point mode. Of note, a pinhole rupture of the balloon occurred in the first 2 cases of our series, during the use of MCS, without harm to the patient and requiring only replacement of the LBA. Conclusions In our case series, laser balloon ablation with the help of motor control system appears safe and feasible in most cases for large portions of pulmonary vein circumference, providing considerable time sparing (66.1% of total ablation extent in 23.6% of total ablation time).

Fungal Endocarditis in a Preterm Neonate

Invasive fungal infections (IFIs) are an important cause of neonatal mortality and morbidity. A total of 5% of IFIs are complicated by fungal endocarditis. Mortality can be as high as 50%. We present a preterm, very low birth weight infant with infective endocarditis. Echocardiography showed a large pedunculated vegetation attached to the inferior vena cava and right atrium junction. Baby had Candida tropicalis in his blood cultures and was managed conservatively with antifungals. Surgery although planned was not possible considering baby being preterm with very low birth weight.

Repair of sinus venosus defects with partial anomalous pulmonary venous connection in adult: Four surgical procedures for a large armamentarium

Surgical repair of sinus venosus defects with partial anomalous pulmonary venous connection (PAPVC) to the superior vena cava (SVC) has been associated with venous return obstructions, and sinus node dysfunction. We aimed to evaluate the safety of four different surgical procedures, for repair of sinus venosus defects with PAPVC, in 23 adult patients, adapted to each patient's specific anatomy assessed by 3D computed tomography. Between March 2010 and May 2019, we performed anatomic repair of sinus venosus defects with a single patch ( n = 6; 26.1%), 2-patch ( n = 9; 39.1%), Warden ( n = 3; 13%), or modified Warden procedure with reconstruction of the divided SVC using a PTFE conduit ( n = 5; 21.7%) ( Fig. 1 ). Median age was 40 years [range, 15 to 73 years]. Main associated procedures were: creation of atrial septal defect ( n = 1), tricuspid valvuloplasty ( n = 2), tricuspid valve replacement ( n = 1), pulmonary valve replacement ( n = 1), monoblock “cut and sew” of pulmonary veins and superior vena cava ( n = 1). Follow-up was 3.26 years [range, 2 months to 10 years]. There were no mortality and no obstruction of SVC and pulmonary veins at the time of discharge and during follow-up. Aortic clamping was shorter (60 ± 39 min) with the single patch technique and longer (112 ± 31 min) with the modified Warden procedure. Nineteen patients (82.6%) had regained sinus rhythm at discharge; a patient with paroxysmal atrial fibrillation had regained a sinus rhythm after the “cut and sew” isolation technique of the superior vena cava and pulmonary veins. All patients were NYHA 1. PAPVC can safely be performed with an appropriate technique, and low morbidity. The single patch technique, when anatomically possible, offers good results but now competes with transcatheter correction. When PAPVC is far from the SVC-right atrium junction, the modified Warden procedure offers an effective and obligatory surgical repair, without any increase in complications.

The Left Atrial Appendage Ostium

The goal of this study was to characterize the location and electrophysiological properties of left atrial appendage (LAA) atrial tachycardia (AT). The LAA has been reported to be a source of AT and atrial fibrillation (AF) triggers. This study retrospectively reviewed ATs mapped to the LAA. Activation and entrainment mapping were used to determine the mechanism and localize each AT circuit/origin. From 2014 to 2018, a total of 45 patients (mean age 65 ± 10 years; 69% male) had 51 LAA ATs: 43 (84%) after AF ablation and 8 de novo (no prior AF). Overall, 50 (98%) were due to localized re-entry/micro–re-entry, whereas only 1 was a focal triggered AT. All 50 micro–re-entrant LAA ATs were mapped to the anterior base (70%) or LAA ridge (30%), and all were successfully treated with focal ablation; no case required LAA isolation. After successful ablation of the initial AT at the LAA base, 23 (62%) of 37 patients with AF also had inducible macro–re-entrant peri-mitral flutter, but none had AF triggers from inside the LAA. LAA ATs are almost always micro–re-entrant in mechanism and originate from either the anterior base or LAA ridge. AT originating from inside the LAA body is very rare. The anterior and ridge aspects of the LAA–left atrium junction seem to be arrhythmogenic hotspots prone to localized re-entry. These ATs are treatable with focal ablation without LAA isolation but are frequently associated with macro–re-entrant peri-mitral flutter.