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Images and Case Reports in Arrhythmia and Electrophysiology

Anomalous Midline Common Ostium of the Left and Right Inferior Pulmonary Veins

Implications for Pulmonary Vein Isolation in Atrial Fibrillation

Ashit G. Patel, MD; Tom Clark, RCIS; Ronald Oliver, BSEE; Eric C. Stecker, MD; Michael D. Shapiro, DO; Karl Stajduhar, MD; Jack Kron, MD; John H. McAnulty, Jr, MD and Sumeet S. Chugh, MD

From the Cardiac Arrhythmia Center, Division of Cardiovascular Medicine, Oregon Health and Science University, Portland, Ore.

Correspondence to Sumeet S. Chugh, MD, The Heart Institute, Cedars-Sinai Medical Center, South Tower 5702, 8700 Beverly Blvd, Los Angeles, CA 90048. E-mail chughs@cshs.org

An extract of the first 250 words of the full text is provided, because this article has no abstract.

A 41-year-old man with a history of paroxysmal symptomatic atrial fibrillation refractory to antiarrhythmic drug therapy was referred for pulmonary vein (PV) isolation. Before the procedure, he underwent standard cardiac computed tomographic angiography to evaluate left atrium and PV anatomy, which revealed single right and left superior PVs, each with a moderate-sized ostium. However, the right and left inferior PVs originated from a common and unusually large ostium in the midpostero-inferior left atrium (Figure). Using a double trans-septal approach, an 8-mm tip deflectable ablation catheter and a 20-pole LASSO catheter were inserted in the left atrium. We performed a 3D reconstruction of the chamber using CARTO-Merge and were able to confirm the findings of computed tomographic angiography imaging.

View larger version (36K):   Figure. A and B, Standard computed tomography image projections in the oblique axial (A) and sagittal (B) views. The right and left inferior pulmonary veins can be seen entering the left atrium via an unusually large common ostium (asterisk) located in the midpostero-inferior left atrium. The close proximity of the common ostium to the esophagus is also noted (arrow). The 3D volume-rendered image (C) also depicts the common ostium of the inferior pulmonary veins (asterisk). Proximity to the esophagus has implications for the approach to pulmonary vein isolation.

 
Given the infero-posterior and midline location of the large common inferior vein ostium located directly over the esophagus, we opted to first isolate the superior veins using individual circumferential ablation around the ostium of each vein. Atrial fibrillation terminated during the process . . . [Full Text of this Article]