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19.03.2020 | Image Puzzle – Answer Open Access

A patient with recurrent palpitations and unusual anatomy

Zeitschrift:
Netherlands Heart Journal
Autoren:
C. J. M. Lawson, A. D. Margulescu, J. Barry

Answer

Complete atresia of the inferior vena cava (IVC) with cavo-azygos (CA) continuity was diagnosed by contrast venography performed using a long sheath (SL0, Abbott Medical, USA) (Fig.  1a). Following the CA vein route, a decapolar and a quadripolar catheter were advanced into the superior vena cava, right atrium, and then into the coronary sinus and right ventricle, respectively (Fig.  1b). However, the right subclavian vein needed to be used to map the triangle of Koch with the ablation catheter, due to better reach and stability at this region compared with the CA route (Fig.  1c).
IVC atresia with CA continuity is a rare congenital anomaly that results from lack of interruption of the right cardinal vein at the level of the diaphragm during embryological development [ 1]. As a result, the intrahepatic trajectory of the IVC is not formed, and the hepatic veins will drain separately into the right atrium. Fig.  1d shows a schematic representation of normal venous anatomy vs. CA continuity. CA continuity may be associated with more extensive embryological abnormalities, such as the heterotaxy syndrome (abnormal arrangement of internal organs across the left-right axis of the body) [ 2]. In our patient, chest X‑ray, abdominal ultrasound and echocardiogram revealed normal internal organ arrangement.
For electrophysiology procedures, IVC atresia with CA continuity can cause significant challenges, especially if left atrial access is required, because the impossibility of performing transseptal puncture through the usual inferior approach [ 3, 4]. However, right-sided ablations (including ablation of atrioventricular nodal re-entrant tachycardia) can be performed with small variations of standard techniques, by looping the catheters back into the right cardiac chambers through the superior vena cava, as demonstrated in this case.

Conflict of interest

C.J.M. Lawson, A.D. Margulescu and J. Barry declare that they have no competing interests.
Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://​creativecommons.​org/​licenses/​by/​4.​0/​.
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