Kupics Kaspars, Jubele Kristine, Nesterovics Georgijs, Erglis Andrejs
Latvian Centre of Cardiology, Pauls Stradins Clinical University Hospital, Pilsonu iela 13, Riga LV-1002, Latvia.
Faculty of Medicine, University of Latvia, Jelgavas iela 3, Riga LV-1004, Latvia.
Eur Heart J Case Rep. 2021 Nov 30;5(12):ytab480. doi: 10.1093/ehjcr/ytab480. eCollection 2021 Dec.
Pulmonary vein isolation (PVI) has entrenched itself as one of the main approaches for the treatment of paroxysmal symptomatic atrial fibrillation (AF). Pulmonary vein isolation prevents focal triggers from pulmonary veins from initiating AF paroxysms. As standard-PVI is performed through the inferior vena cava (IVC) approach, through the femoral vein. However, there are conditions when this approach is not appropriate or is not available.
We report a case of a 53-year-old male who was referred to Pauls Stradins Clinical University Hospital for PVI due to worsening AF. Due to the rare anatomical variant of the venous system, the standard approach to PVI could not be applied. Interrupted cava inferior did not allow for femoral vein and IVC access. We had to figure out a different path-a combination of internal jugular and subclavian veins was used. Transseptal puncture was performed under transoesophageal echocardiography (TOE) control with a puncture needle stiletto. Pulmonary veins were isolated successfully, no complications were observed, and the patient was discharged in sinus rhythm.
In some patients, PVI cannot be done through the standard IVC approach. In such cases, a different venous access must be chosen. Our patient had a rare variant of interrupted IVC and we had to use superior vena cava approach for the procedure. The difficulty of this approach is that procedure instruments are not designed for non-standard venous access; however, a combined use of TOE, general anaesthesia, and contact force-guided ablation has succeeded in isolating patients' pulmonary veins.
肺静脉隔离术（PVI）已成为治疗阵发性症状性心房颤动（AF）的主要方法之一。肺静脉隔离可防止肺静脉的局灶性触发因素引发房颤发作。标准的肺静脉隔离术是通过下腔静脉（IVC）途径，经股静脉进行。然而，在某些情况下，这种方法并不合适或无法实施。
我们报告一例53岁男性患者，因房颤病情加重被转诊至保罗·斯特拉迪恩斯临床大学医院接受肺静脉隔离术。由于静脉系统存在罕见的解剖变异，无法应用标准的肺静脉隔离术方法。下腔静脉中断使得无法经股静脉和下腔静脉进入。我们不得不另辟蹊径——采用颈内静脉和锁骨下静脉联合的方式。在经食管超声心动图（TOE）引导下，使用穿刺针芯进行经房间隔穿刺。成功隔离了肺静脉，未观察到并发症，患者出院时处于窦性心律。
在一些患者中，无法通过标准的下腔静脉途径进行肺静脉隔离术。在这种情况下，必须选择不同的静脉入路。我们的患者存在下腔静脉中断的罕见变异，因此不得不采用上腔静脉途径进行该手术。这种方法的困难在于手术器械并非为非标准静脉入路设计；然而，联合使用经食管超声心动图、全身麻醉和接触力引导消融成功地隔离了患者的肺静脉。
