Atrial fibrillation resulting from superior vena cava drivers addressed with cryoballoon ablation: Late reconnection at the site of phrenic nerve pacing.

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Atrial fibrillation resulting from superior vena cava drivers addressed with cryoballoon ablation: Late reconnection at the site of phrenic nerve pacing catheter Ben Ng, MBBS, Rahn Ilsar, MBBS, PhD, Mark A. McGuire, MBBS, PhD, Suresh Singarayar, MBBS, PhD HeartRhythm Case Reports Volume 5, Issue 1, Pages 10-14 (January 2019) DOI: 10.1016/j.hrcr.2018.09.010 Copyright © 2018 Terms and Conditions

Figure 1 Chronological reports from the implantable cardiac monitor. A: Episodes of paroxysmal atrial fibrillation leading into the index procedure (white arrow), absence of detected tachyarrhythmias over the following 8 months, and subsequent recurrence of atrial arrhythmias (black arrow). B: Recurrence in the atrial arrhythmia burden and no further events following reisolation of the superior vena cava (white arrow). AT/AF = atrial tachycardia/atrial fibrillation; V. rate = ventricular rate. HeartRhythm Case Reports 2019 5, 10-14DOI: (10.1016/j.hrcr.2018.09.010) Copyright © 2018 Terms and Conditions

Figure 2 Intracardiac electrograms with the Achieve catheter (labeled PV [pulmonary vein] and SVC [superior vena cava] in the respective panels) and coronary sinus catheter (labeled CS). A: The Achieve catheter in the right superior pulmonary vein (RSPV), demonstrating spontaneous activity (box) while atrial fibrillation is seen on the CS catheter, reflecting electrical isolation. Low-amplitude activity is observable in the background, most prominently the distal electrodes of the RSPV, reflecting far-field signals from the SVC and appearing to organize at the end. Artefact from phrenic nerve pacing has been marked (white arrow). B: The Achieve catheter in the RSPV, as the tachycardia became organized, demonstrating apparent 2:1 conduction into the atria, following isolation of the vein. C: The Achieve catheter in the SVC postisolation, demonstrating independent rapid activity in the SVC, not perturbing rhythm in the atria or initiating atrial arrhythmias. HeartRhythm Case Reports 2019 5, 10-14DOI: (10.1016/j.hrcr.2018.09.010) Copyright © 2018 Terms and Conditions

Figure 3 Fluoroscopic views demonstrating superior vena cava (SVC) occlusion and catheter positions: A: Right anterior oblique. B: Left anterior oblique. C, D: Corresponding views of CARTO 3 activation maps of the right atrium, with annotation of the sites of earliest activation (white), ablation (red), and phrenic capture (yellow): C: right anterior oblique; D: left anterior oblique. HeartRhythm Case Reports 2019 5, 10-14DOI: (10.1016/j.hrcr.2018.09.010) Copyright © 2018 Terms and Conditions