VARIPULSE pulsed-field ablation via superior venous access in interrupted inferior vena cava with azygos continuation: a case report

Interrupted inferior vena cava with azygos continuation may make conventional transfemoral transseptal access impractical for atrial fibrillation ablation. A 61-year-old man with symptomatic persistent atrial fibrillation was referred for catheter ablation. During the procedure, atypical intracardiac echocardiographic and coronary-sinus catheter findings prompted venography, which demonstrated interruption of the hepatic segment of the inferior vena cava with azygos continuation. Because the circuitous transfemoral route through the azygos vein was unsuitable for conventional transseptal access, pulmonary vein isolation was performed through a right internal jugular vein-superior vena cava approach. Intracardiac echocardiography, CartoSound anatomical reconstruction, three-dimensional electroanatomical mapping, and a visualizable bidirectional steerable sheath were used to plan the superior transseptal trajectory and guide catheter manipulation. Because a conventional mechanical transseptal vector was unfavorable, imaging-guided electrocautery-assisted J-wire puncture was used to obtain left atrial access. VARIPULSE pulsed-field ablation was delivered at 1800 V as 18 applications, each comprising three pulses, for 54 pulses in total. Acute isolation of all pulmonary veins was confirmed by voltage remapping and entrance and exit block testing. No pericardial effusion, clinically apparent thromboembolic event, or access-site complication occurred. At 3-month follow-up, the patient reported no atrial fibrillation-related symptoms and had no AF detected on monthly 24-hour Holter monitoring; dronedarone was discontinued at the 3-month visit. This case describes a stepwise multimodality workflow for superior-access VARIPULSE pulmonary vein isolation in selected patients with interrupted inferior vena cava and azygos continuation; longer rhythm follow-up is required. This case describes a stepwise multimodality workflow ...; longer rhythm follow-up is required.