doi: 10.1161/CIRCEP.108.801936
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
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{at}cshs.org
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.
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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 of ablation around the left superior vein. Both superior PVs were isolated using RF with successful achievement of conduction block between left atrium and both veins, after which atrial fibrillation was no longer inducible both with and without infusion of isoproterenol 6 µg/min. The common ostium of the inferior veins was now cannulated with the ablation catheter, and narrow nonfractionated PV potentials were recorded. However, because of the direct proximity of the common inferior PV ostium to the esophagus, we elected not to isolate the inferior veins. At the present time, 3-month follow-up is available and reveals no recurrence of atrial fibrillation.
The 2 most common PV anomalies are the presence of a right middle PV and common left trunk.1 The inferior common ostium is an unusual PV anomaly not described before in the context of PV isolation. However, one report of this anomaly was recently published in the computed tomography literature by one of the authors.2 Given the altered location of the inferior vein ostium, there are obvious implications for potential increased risk of esophageal perforation. With the burgeoning number of radiofrequency ablation procedures, advance knowledge of PV anatomic variants can be critical for the clinical electrophysiologist. This case demonstrates the utility of cardiac imaging before PV isolation procedures.
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1. Marom EM, Herndon JE, Kim YH, McAdams HP. Variations in pulmonary venous drainage to the left atrium: implications for radiofrequency ablation. Radiology. 2004; 230: 824–829.
2. Shapiro M, Dodd JD, Brady TJ, Abbara S. Common pulmonary venous ostium of the right and left inferior pulmonary veins: an unusual pulmonary vein anomaly depicted with 64-slice cardiac computed tomography. J Cardiovasc Electrophysiol. 2007; 18: 110.[CrossRef][Medline]
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