|Year : 2022 | Volume
| Issue : 1 | Page : 51-54
An unusual association of left-sided inferior vena cava with slow-fast atrioventricular reentrant tachycardia
Debasish Das, Tutan Das, Subhas Pramanik
Department of Cardiology, AIIMS, Bhubaneswar, Odisha, India
|Date of Submission||02-Jul-2021|
|Date of Decision||29-Nov-2021|
|Date of Acceptance||09-Feb-2022|
|Date of Web Publication||26-Apr-2022|
Department of Cardiology, AIIMS, Bhubaneswar, Odisha
Source of Support: None, Conflict of Interest: None
We report an extremely rare association of left-sided inferior vena cava (IVC) in a 38-year-old female presenting with recurrent palpitation for the past 2 years with typical slow-fast atrioventricular reentrant tachycardia (AVNRT). We delineated the course of the left-sided IVC with pigtail injection and catheter course to the right atrium and successfully modified the slow pathway with conventional catheters with difficulty in ablation catheter maneuvering and his catheter stability was an issue. Our case is the first description of an unusual association of isolated left-sided IVC in a patient with typical AVNRT.
Keywords: Atrioventricular reentrant tachycardia, inferior vena cava, left sided
|How to cite this article:|
Das D, Das T, Pramanik S. An unusual association of left-sided inferior vena cava with slow-fast atrioventricular reentrant tachycardia. J Pract Cardiovasc Sci 2022;8:51-4
|How to cite this URL:|
Das D, Das T, Pramanik S. An unusual association of left-sided inferior vena cava with slow-fast atrioventricular reentrant tachycardia. J Pract Cardiovasc Sci [serial online] 2022 [cited 2022 May 25];8:51-4. Available from: https://www.j-pcs.org/text.asp?2022/8/1/51/344129
| Introduction|| |
Atrioventricular nodal reentrant tachycardia is the most common paroxysmal supraventricular tachycardia encountered by electrophysiologists and the most common lesion for which radiofrequency ablation is performed. Recently, slow pathway modification has been made relatively easier with the use of three catheters; one for his, one for coronary sinus, and one radiofrequency ablation catheter. Electrophysiologists usually do not expect the coexisting anatomic abnormality to reach the right atrium before slow pathway modification. We were not able to negotiate the routine guidewire in the right paravertebral plane after routine right femoral venous access; each time the guidewire was making an inverse U loop and curving downward. Incidentally, the guidewire crossed the spine to the left side, we feared that it may be a catastrophic iatrogenic aortocaval connection but pigtail injection delineated the presence of the left-sided IVC. Left-sided vena cava is also known as transposition of vena cava which is the most common anomaly of inferior vena cavae (IVCs) and occurs due to persistence of the left supracardinal vein. We successfully modified the slow pathway; our case is the first description of an unusual association of isolated left-sided IVC with typical slow-fast atrioventricular reentrant tachycardia (AVNRT) in a middle-aged female.
| Case Report|| |
Thirty-eight-year-old nondiabetic, nonhypertensive female presented to the cardiology outpatient department with recurrent palpitation for the past 2 years. She had six episodes of palpitation with four episodes self-terminating and two episodes reverted with adenosine. She had a structurally normal heart in routine echocardiography and was euthyroid and serum chemistry was within normal limit. Prior documented EKG revealed that tachycardia around 180 beats/min with pseudo r wave in V1 and automatic voltage regulator and pseudo S wave in inferior leads suggestive of likely AVNRT and was subjected for radiofrequency ablation. After routine right femoral venous access, we were not able to negotiate the routine guidewire further in the right paravertebral plane [Figure 1] which was making an inverse U loop and bending downward. Initially, we thought that we are dealing with an interrupted IVC or stenosed IVC for which we tried to negotiate with a softer terumo wire which crossed the spine and ascended in the left paravertebral plane. Although terumo-induced great artery perforation is not described till now, for a fraction of a second, we thought that we have done an iatrogenic aortocaval connection but the patient's hemodynamics was quite stable. We negotiated a 5F pigtail catheter and pigtail injection (20 ml, 600 psi with flow rate of 10 ml/min) clearly delineated left-sided IVC [Figure 2]. We negotiated the wire further which crossed from left to right again at the level of the renal artery [Figure 3] which is the conventional course of the left-sided IVC and a subhepatic pigtail injection clearly delineated the drainage of left-sided IVC to the right atrium [Figure 4]. We proceeded for radiofrequency ablation with conventional three catheters, antegrade pacing-induced AH jump and initiation of V on A tachycardia [Figure 5] and entrainment suggested it to be AVNRT (Post Pacing Interval – Tachycardia Cycle length-TCL>115 ms). There was although difficulty in positioning a unidirectional ablation catheter in Koch's triangle, we used a long sheath with a stiffer bidirectional ablation catheter [Figure 6] to provide more stability during ablation in spite of the presence of sharp 90° suprarenal turn of the left-sided IVC, delivered ablation lesion in mid-Koch's triangle, achieved sustained, good, and irregular junctional rhythm, and postradiofrequency ablation AH block was demonstrated and tachycardia was not inducible. Left antecubital vein injection revealed no persistence of left superior vena cava (LSVC) [Figure 7]. There has been a paucity of literature description of the association of left-sided superior vena cava in the presence of left-sided IVC. In the event of inadvertent complete heart block during AVNRT ablation, presence of LSVC is of paramount importance before permanent pace maker implantation. Because of an incidental detection of left-sided IVC anomaly, we did a computed tomography abdomen to rule out associated anomaly as a part of syndromic associations and it was within normal limit. Chest X-ray was also within the normal limit. She did not have any dysmorphic features and was born out of nonconsanguineous marriage, and family history revealed no obvious structural deformity in the family members. Our case has a take-home message, during simple ablation of typical AVNRT, never push the guidewire too hard always assuming a right-sided IVC; it may be a left-sided IVC, and inadvertent force to negotiate across the right paravertebral plane may land in a catastrophe like retroperitoneal bleed. Our case is an extremely rare description of an unusual association of isolated left-sided IVC with typical slow-fast AVNRT.
|Figure 5: Initiation of atrioventricular reentrant tachycardia during antegrade pacing with critical atrioventricular delay|
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| Discussion|| |
Left-sided vena cava refers to a variant course of IVC. It is the most common anomaly of IVC but its association with typical AVNRT has not been described so far. A left-sided IVC usually ends at the left renal vein and crosses anteriorly to join the normal prehepatic segment of IVC [Figure 8]. Sometimes, it crosses more posterior to the aorta. Distally, the IVC is formed by the confluence of the common iliac veins. Anomalies of IVC include left-sided IVC, absent infrarenal IVC, duplication of IVC, circumaortic venous collar, retro aortic left renal vein, and azygous continuation of IVC. Left-sided IVC is an extremely rare anomaly. Khamanarong et al. encountered one case of left-sided IVC out of 939 embalmed cadaveric dissection between 1974 and 2008 and he described the anomaly as left-sided IVC formed behind the left common iliac artery at L5 vertebra and coursed proximally on the left of the aorta till it reached the left renal vein and then crossed anterior to the abdominal aorta to assume the normal right side. At the point of crossing, it received the left renal vein and the right renal vein emptied into the IVC on right side. The great importance of this left renal vein is there while carrying out the laparoscopic urologic surgery. Left-sided IVC may be associated with abdominal aortic aneurysm and aortoiliac occlusive disease as described in two case reports by Gil et al.
|Figure 8: (1) Hepatic cava, (2) Suprarenal cava. (3) Renal cava. (4) Left renal vein. (5) Infrarenal cava. (6) Iliac vein|
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During electrophysiology procedures, one must be extremely gentle while crossing from left to right or across infrarenal cava to renal cava to suprarenal cava as the catheter has to take two 90° turns [Figure 8] and these two bends create difficulty in placing the ablation catheter in Koch's triangle. Also, the presence of such two bends in IVC makes the His catheter unstable. There remains a risk of inadvertent caval perforation while crossing from left to right with two 90° angles. Inadvertent injury to the IVC may result in thrombosis of IVC. Left-sided vena cava is a rare anatomic abnormality encountered in 0.17%–0.5% of the general population. The presence of left-sided IVC carries great significance during renal transplant and urologic surgeries. Young electrophysiologists while facing difficulty in negotiating a guidewire across the right paravertebral plane should think of the presence of a left-sided IVC. When left-sided IVC runs retroaortic course, it is usually associated with multiple renal veins., Park and Bae described an unusual left-sided vena cava with retrohepatic crossing over with intrahepatic venocaval shunts. This patient presented with chronic liver disease with elevated transaminase and hypoalbuminemia. Cases of left-sided IVC causing intermittent celiac artery compression syndrome with IVC anterior to the aorta at the level of the celiac trunk and compression of left IVC coursing anterior to abdominal aorta between the aorta and superior mesenteric artery also known as nutcracker phenomenon have been described. Manoharan described incidental detection of a left-sided IVC in a patient with renal cell carcinoma. Abdominal ultrasound easily picks up the left-sided IVC but routine ultrasonography examination is usually not needed before an elective electrophysiology procedure. Elhattabi et al. described the presence of left-sided IVC in a patient with pancreatic head carcinoma. Runwal reported a case of interrupted left-sided IVC draining into persistent LSVC with left isomerism. Brickner et al. reported a case of left-sided IVC draining into coronary sinus through persistent LSVC. Karthigesan and Jayaprakash reported successful radiofrequency ablation of AVNRT in a case of left-sided IVC draining into the coronary sinus through persistent LSVC. Deshpande and Udyavar described radiofrequency ablation of typical AVNRT in persistent LSVC. Few technical issues pertain to this anatomic abnormality like catheter negotiation must be slow and gentle in the case of left-sided IVC while crossing from left to right across two 90° angles, His catheter should be properly fixed because stability becomes an issue with this half S turn of IVC and bidirectional ablation catheter should be used for better maneuverability in this anomalous left-sided IVC.
| Conclusion|| |
Our case is the first description of radiofrequency ablation of typical AVNRT with associated isolated left-sided vena cava. Electrophysiologists should think of this anomaly while facing difficulty in the negotiation of guidewire across the right paravertebral plane. Gentle crossing from left to right, proper stabilization of his catheter, and use of bidirectional ablation catheter are simple clues for successful radiofrequency ablation in a case of left-sided IVC.
Institutional Ethical Committee (IEC) clearance has been obtained.
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.
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Conflicts of interest
There are no conflicts of interest.
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