Author + information
- Received August 1, 2018
- Revision received August 14, 2018
- Accepted August 16, 2018
- Published online December 17, 2018.
- Kanae Hasegawa, MD, PhD,
- Shinsuke Miyazaki, MD, PhD∗ (, )
- Kenichi Kaseno, MD, PhD and
- Hiroshi Tada, MD, PhD
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
- ↵∗Address for correspondence:
Dr. Shinsuke Miyazaki, Department of Cardiovascular Medicine, Faculty of Medical Sciences, University of Fukui, 23-3 Matsuokashimoaizuki, Eiheiji-cho, Yoshida-gun, Fukui 910-1193, Japan.
A 78-year-old woman with persistent left superior vena cava (PLSVC) underwent a second ablation procedure for persistent atrial tachycardia (AT). She had undergone cryoballoon pulmonary vein isolation, left atrial (LA) roof and mitral isthmus linear ablation of atrial fibrillation 15 months earlier. The starting rhythm was stable AT with a cycle length of 215 ms. An ultra-high resolution activation mapping and entrainment mapping revealed that the mechanism of the AT was macro–re-entry between PLSVC and LA (Figures 1A to 1C, Online Video 1). In the PLSVC, the propagation exhibited a focal pattern from the distal PLSVC. On the contrary, the earliest LA activation was a wide area in the inferior LA, suggesting multiple connections between the coronary sinus ostium and LA. A single point application at the earliest PLSVC activation site terminated the tachycardia (Figure 1D, Online Figures 1A and 1B), and a subsequent application during pacing from the LA appendage resulted in a transient but persistent LA-distal PLSVC block. However, a single application at the opposite endocardial site immediately resulted in permanent LA-distal PLSVC block (Figure 1E, Online Figure 1C). A differential pacing and ultra-high resolution mapping during PLSVC pacing confirmed the bidirectional LA-PLSVC block at distal PLSVC level (Figure 1F, Online Video 2).
The arrhythmogenicity of the ligament of Marshall has been well known, and embryologically the PLSVC regresses to become a ligament. The distal ligament of Marshall connects to the LA, and recently, a ridge-related AT via ligament of Marshall epicardial connection after mitral isthmus linear ablation has been reported (1). Similarly, the PLSVC connects to the LA at both the distal and proximal level (i.e., coronary sinus ostium) (2). In the present case, the former was a single connection and the latter was likely multiple wide connections. Therefore, the only narrow isthmus of this AT was the connection site between the LA and distal PLSVC. Sequential unipolar epicardial and endocardial applications successfully eliminated this connection. To the best of our knowledge, this is the first reported case of PLSVC-related AT.
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
All authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the JACC: Clinical Electrophysiology author instructions page.
- Received August 1, 2018.
- Revision received August 14, 2018.
- Accepted August 16, 2018.
- 2018 American College of Cardiology Foundation
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