The SL1 was replaced with a Vizigo sheath.įluoroscopic images showing placement of the catheters. It was difficult to get the dilator and the Agilis sheath across the septum so we exchanged the Agilus with the SL1, which was unfruitful too. A 0.035mm caliber wire was advanced through the transseptal puncture site. The puncture site was relatively superior on the septum. The Baylis wire was placed the septum and the transseptal puncture was performed. Since extreme difficulty was faced to maintain the needle at the septum, we decided to use the Baylis wire instead of the needle. As we would advance the needle, the sheath would fall off the septum despite curve changes. We advanced a Baylis needle into the Agilis sheath. ICE images were reversed (superior to inferior) in order to visualize the septum as coming from the IVC. Intravenous heparin bolus (100U/kg) was given to maintain active clotting time (ACT) between 250-300. Intra-cardiac Echo (ICE) catheter was advanced and positioned. Left axillary vein was cannulated and a 10-French sheath and an Agilis sheath were advanced and positioned. Left subclavian venous access was found to be appropriate after peripheral venography. Taking into consideration that our patient was in therapeutic INR (for transhepatic approach the INR is vital to be within normal range) and, furthermore, that the patient’s family required the procedure to be done as scheduled, it was decided to move forward with right subclavian access through which a deflectable catheter was advanced and positioned in the coronary sinus (CS) for left atrial (LA) pacing and recording purposes. Peripheral venography revealed no flow through the IVC filter We discussed the options we had with the patient’s family: transhepatic access, subclavian access or referral for epicardial approach. Peripheral venography revealed complete occlusion of the venous system with no flow through the IVC filter. Right femoral vein cannulation with modified Seldinger technique was performed, but advancing the guidewire through the IVC was extremely difficult. He continued to have bouts of breakthrough AFib and hence was referred to us for ablation.ĭue to highly symptomatic pharmacological uncontrolled AFib, RFA was decided in order to achieve long term success in restoring NSR.TEE on the day of procedure excluded clot or thrombus. The patient was scheduled for transesophageal echocardiography (TEE) cardioversion on amiodarone, but he spontaneously converted into normal sinus rhythm (NSR) and his symptoms improved. ECG recordings during the office visit revealed AFib with aberrant conduction as supported by previous Holter monitoring. Despite being on amiodarone, the patient developed symptomatic, persistent AFib (limitation in daily activities) with worsening AFib burden resulting in deterioration of left ventricular EF. A 87 year old male patient with a history of recurrent AFib, coronary artery disease (CAD), IVC filter placement, for recurrent deep venous thrombosis, essential hypertension(HTN) and cardiomyopathy (ejection fraction (EF)=40%) was referred for an EP consult. We present a case report of PVI and Posterior Wall Isolation performed via the left subclavian access. In rare cases of congenital or iatrogenic obstruction of inferior vena cava (IVC), RFA of arrhythmias are performed through a transhepatic approach. These procedures are typically performed via femoral vein approach and all devices are designed to be delivered via inferior access. The success rate is shown to be more than 90% and the recurrence rate was less than 10% when complete block of the isthmus was achieved. Typical Atrial Flutter (AF) is generated by a large, counterclockwise reentry circuit in the right atrium and can be successfully eliminated by RFA of cavotricuspidisthmus (CTI) area which is slowly conducting. Pulmonary vein isolation (PVI) via catheter ablation via femoral approach is a widely applied technique. In 1996, the Bordeaux group noted that AFib is initiated by rapidly firing triggers located in the pulmonary veins. Besides being often symptomatic due to high ventricular rates, it is responsible for functional limitation and cardiomyopathy induced by tachycardia. Ītrial Fibrillation (AFib) is the most common chronic rhythm disorder encountered in clinical practice. RFA is recommended as first-line therapy in patients with paroxysmal or persistent AF with minimal structural heart disease. Radiofrequency Ablation (RFA) has become a well-recognized non-pharmacological treatment strategy for many cardiac arrhythmias because of a high success rate and low risk of complications.
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