Pulmonary Vein and Left Atrial Posterior Wall Isolation Using a Balloon-in-Basket Pulsed-Field Ablation Catheter via the Superior Vena Cava Approach in a Patient with Interrupted Inferior Vena Cava: A Case Report

Abstract Background Pulmonary vein isolation (PVI) is the cornerstone of catheter ablation for atrial fibrillation (AF) and is typically performed via transfemoral access. In patients with interrupted inferior vena cava (IVC), however, alternative access routes such as superior vena cava (SVC) approach are required. A balloon-in-basket (BiB)-pulsed field ablation (PFA) is a novel non-thermal ablation modality that offers stable positioning and uniform tissue contact. Case summary A 66-year-old male with symptomatic persistent AF characterized by palpitations and interrupted IVC was referred to our institution. Catheter ablation using a BiB-PFA system via the SVC approach was planned. Transseptal puncture was successfully achieved under transesophageal echocardiographic and fluoroscopic guidance. PVI was achieved using the BiB-PFA catheter. Additional left atrial posterior wall (LAPW) isolation was performed with selective electrode activation to avoid anterior wall delivery. The procedure was completed without complications. At the 3-month follow-up, no recurrence of atrial tachyarrhythmia was detected on Holter monitoring, and the patient remained asymptomatic. Discussion This case highlights the feasibility and safety of performing PVI and LAPW isolation via the SVC approach using the BiB-PFA system in a patient with interrupted IVC. The BiB-PFA system provides stable catheter manipulation and allows targeted lesion delivery through selective electrode activation. Although limited by its single-case nature and short follow-up, this report suggests that the BiB-PFA system may expand the therapeutic options for patients with complex venous anatomy.