A case of bidirectional conduction block within the superior vena cava induced by cryoballoon pulmonary vein isolation

A 53‐year‐old male underwent a pulmonary vein isolation (PVI) of atrial fibrillation (AF) with a second‐generation cryoballoon (CB). Although the patient maintained sinus rhythm after the PVI, a superior vena cava (SVC) fibrillation was recorded by a circular‐multipolar‐electrode catheter positioned inside the SVC that suggested conduction block between the right atrium (RA)‐SVC connection. An adenosine triphosphate intravenous injection induced a dormant reconnection of the SVC myocardial sleeve and converted sinus rhythm to an AF rhythm. This case demonstrated that a CB application for the isolation of a right superior pulmonary vein could induce an electrical conduction block between the RA‐SVC connection.     

上腔静脉置换术中体外静脉-静脉压差式转流的临床应用探讨

目的评价体外静脉-静脉压差式转流在上腔静脉置换术中的临床应用价值。方法选取2004年-2006年我院实施上腔静脉切除人造血管重建术无神经系统合并症的患者。术中应用体外静脉-静脉压差式转流。术中持续监测动脉血压、颈内静脉压。于转流前、转流后、阻断后5min、15min、40min及开放后5min、1h经颈内静脉、桡动脉同时抽血行血气分析。术毕随访呼唤睁眼时间及神经系统相关并发症。结果术中动脉血压无变化。阻断期间颈内静脉压升高,平均动脉压与颈内静脉压差及颈内静脉氧饱和度（SjvO2）下降。开放后上述三者均迅速恢复至基础水平。所有患者术毕呼唤睁眼,无神经系统并发症发生,痊愈出院。结论体外静脉-静脉压差式转流操作简单、无污染、可控性好,易维持稳定的血流动力学,改善了脑的血液灌注,是一种安全有效的脑保护临床措施。     

Placement of a temporary pacemaker electrode through a persistent left superior vena cava

Perioperative temporary pacing was needed in a patient with congenital skeletal malformations and a cardiac conduction disturbance with incomplete trifascicular block. We report the successful placement of the pacemaker electrode through a persistent left superior vena cava (SVC). Received: 8 September 1997 Accepted: 3 March 1998     

Persistent left superior vena cava: case report and literature review

A persistent left superior vena cava (PLSVC) is the most common thoracic venous anomaly. It is a persistent remnant of a vessel that is present as a counterpart of normal right-sided superior vena cava (SVC) in early embryological development but normally disappears later. Although it can be easily diagnosed by the characteristic chest radiographic appearance of a pulmonary artery catheter (PAC) passed through it after being inserted into the left subclavian or jugular vein, its diagnosis is usually missed by the presence of normal (right) SVC and the passage of the catheter on the right side. Its diagnosis can be confirmed by many noninvasive and invasive tests, or it is incidentally diagnosed at thoracic surgery or autopsy. If it is not associated with other congenital cardiac anomalies, it is usually asymptomatic and hemodynamically insignificant. However, PLSVC has important clinical implications in certain situations. In this article, we describe a patient with bilateral SVC (a normal right SVC and a PLSVC) identified by a PAC in the PLSVC and the pacemaker wires in the right SVC. In addition, we review the literature on prevalence, embryological development, diagnosis, and clinical implications of PLSVC.     

Percutaneous stenting of malignant superior vena cava syndrome in a patient with persistent left and absent right superior vena cava

Stent placement is the preferred means of managing malignant obstruction of the superior vena cava (SVC). Persistent left and absent right SVC is a very rare venous anomaly. We here report the case of a 58-year-old man who underwent percutaneous stenting for malignant persistent left and absent right SVC obstruction caused by advancement of adenocarcinoma of the upper lobe of the left lung. The patient became symptom-free one day after endovascular stenting through the right femoral vein. However, he experienced repeated supraventricular tachycardia during the procedure. To our knowledge, this is the first report of stenting for malignant SVC obstruction with this congenital anomaly.     

布-加综合征合并上腔静脉阻塞诊治分析

目的探讨布一加综合征合并上腔静脉阻塞的诊断与治疗方法。方法本组3例布一加综合征术前均经腹部彩超及磁共振静脉成像检查确诊，上腔静脉阻塞经上腔静脉造影证实。3例下腔静脉均狭窄闭塞行球囊扩张成形术；例1上腔静脉入右房口处狭窄采用球囊单纯扩张，例2、3因无明显上腔静脉阻塞症状且上腔静脉完全闭塞导丝无法通过而未行介入处理。结果3例介入手术后下腔静脉压力分别由术前的23．33、25．88和17．55mmHg降至9．60、9．60和7．20mmHg。例1上腔静脉压力由术前16．58mmHg降至术后6．98mmHg。3例术后皆恢复顺利，出院。随访症状完全消失、肝肾功能恢复正常。结论对布一加综合征患者术前应充分了解上腔静脉通畅情况，避免漏诊上腔静脉阻塞。对上腔静脉阻塞症状较轻或无症状者可不予处理，症状较重者应根据病因进行治疗。     

Influence of Anodal Electrode Position on Transvenous Defibrillation Efficacy in Humans: A Prospective Randomized Comparison

Nonthoracotomy lead systems for implantable cardioverter defibrillators (ICDs) have reduced operative mortality and morbidity as compared to epicardial lead systems but are usually associated with higher defibrillation thresholds (DFTs). The purpose of this prospective randomized trial was to investigate if the second defibrillation electrode in the left subclavian vein can increase defibrillation efficacy and decrease DFT as compared to the superior vena cava (SVC) position in nonthoracotomy lead systems for ICDs. Seventeen patients (mean age; 49.9 ± 11.3 years, mean ejection fraction; 46.1%± 15.8%) were implanted with an investigational unipolar electrode (Medtronic 13001) used as the defibrillation anode. DFT testing was started in the SVC (n = 10, group A) or the left subclavian vein (n = 7, group B), and repeated in the alternative position starting at the DFT of the initial position. Fifteen patients were eligible for analysis (group A: n = 9, group B: n = 6). With the electrode in the SVC, ventricular fibrillation could be successfully terminated in 9 out of 15 patients (60%). In the left subclavian vein the success rate was 100% (P < 0.01). Mean DFT in the SVC was 13.0 ± 5.2 J and in the left subclavian vein 10.2 ± 4.9 J. DFTs in the left subclavian vein were either lower (group A: n = 5/9, group B: n = 5/6) or equal to the results in the SVC position (P < 0.001). Thus, the left subclavian vein appears to be a superior alternative for positioning of the defibrillation anode as compared to the SVC for nonthoracotomy lead systems using two separate leads.     

Pacemaker Induced Superior Vena Cava Obstruction: Management by Spiral Vein Graft

A 35-year-old male developed superior vena cava (SVC) obstruction due to multiple retained pacemaker leads. This caused cyanosis and suffusion of the head and neck during arm exercise, with desaturation from 99%-90% demonstrated by ear oximetry. The SVC was bypassed using a spiral vein graft because of worsening symptoms. Dramatic improvement resulted, with desaturation no longer demonstrable.     

Intravascular Lead Extraction Using Locking Stylets and Sheaths

BYRD, C.L., ET AL.: Intravascular Lead Extraction Using Locking Stylets and Sheaths. Chronic lead extraction using intravascular countertraction techniques was studied in patients with over 65 different lead models including passive and active fixation devices. Indications for removal of 115 leads implanted 5 days to 264 months (mean 58 months) in 62 patients (mean 65 years) included septicemia, subcutaneous tissue infection, preerosion, free-floating lead, lead trapped in valve, too many leads, pain, and vein thrombosis. The superior vena cava (SVC) approach was attempted in 101 leads and was successful in 82 attempts (71% of total leads). The inferior vena cava (IVC) approach via the femoral vein was required to extract 14 (12%) leads inaccessible to the SVC approach and the 19 leads that failed the SVC approach (29% of total leads). The SVC procedure includes a sized stylet locked at the tip and telescoping sheaths advanced over the lead to the heart. An IVC procedure includes placement of a 16 F sheath workstation via a femoral vein into the right atrium. A deflection catheter and Dotter snare in an 11 F sheath were advanced through the workstation into the right atrium. The lead was maneuvered into position, snared, and pulled into the workstation. For both the SVC and IVC approaches, the leads were removed by applying traction on the lead and countertraction with the sheaths. In experienced hands, these techniques have proven safe and effective for removing chronic transvenous leads.     

Slow pathway ablation for atrioventricular nodal reentry using a right internal jugular vein approach: a case series

BACKGROUND: Inferior venous access to the right heart is not possible in some patients due to congenital or acquired obstruction of the inferior vena cava (IVC). Although right-sided electrophysiology procedures have been performed successfully in patients with a previously placed IVC filter by direct placement of catheters through the filter, an alternative approach is necessary in some patients. METHODS: This case series describes three patients with an IVC filter who underwent successful ablation of the slow pathway for typical atrioventricular (AV) nodal reentrant tachycardia using a superior vena cava (SVC) approach via the right internal jugular (IJ) vein. Two separate introducer sheaths were placed into the IJ vein using separate punctures. This permitted placement of a standard deflectable ablation catheter and an additional catheter in the right atrium to monitor for ventriculoatrial conduction during the junctional rhythm associated with ablation of the slow AV nodal pathway. RESULTS: Catheter ablation was successful in each patient. The number of radiofrequency current applications was 7, 17, and 27. There were no procedural complications and no patient had recurrent tachycardia during follow-up. CONCLUSIONS: Catheter ablation of the slow AV nodal pathway can be performed successfully and safely in patients with inferior venous barriers to the right heart using an SVC approach via the right IJ vein.     

A misfired Greenfield filter; 21 years later!

A 35-year-old male developed deep vein thrombosis (DVT) andpulmonary emboli in 1986. He was subsequently diagnosed withprotein S deficiency. As a high risk for further thromboembolicevents, the patient underwent inferior vena cava (IVC) and superiorvena cava (SVC) Greenfield filter placement at an outside institution(in 1986). At the age of 56 years     

相位对比磁共振成像诊断小儿继发孔型房间隔缺损

目的 探讨相位对比磁共振成像(PC-MRI)在诊断小儿继发孔型房间隔缺损(ASD)中的应用价值. 方法 42例经胸超声心动图证实为继发孔型ASD患儿,年龄9个月～15岁.采用PC-MRI采集通过ASD的左向右分流束的图像,以及缺损边缘与上下腔静脉及二尖瓣、右上肺静脉连线的PC-MRI图像. 结果 42例PC-MRI测量的ASD直径、缺损边缘与上腔静脉、下腔静脉、房室瓣及右上肺静脉间的距离均与经胸超声心动图的结果有很好的相关性(P<0.001).26例PC-MRI测量结果与外科手术结果高度相关(P<0.001),不同流速编码中,流速编码50～70 cm/s时PC-MRI测量到的缺损直径与外科手术结果相对最为一致. 结论 PC-MRI可直观显示房间隔缺损的位置、数目、大小和与周围心内结构的空间关系,同时可进行准确的定量分析, 为心脏解剖畸形诊断提供了一种新的检测方法和思路.     

Importance of Superior Vena Cava Isolation in Successful Ablation of Persistent Atrial Fibrillation in Patient with Partial Anomalous Pulmonary Vein

Ectopic foci arising from pulmonary veins (PVs) are the predominant sources for the initiation and maintenance of atrial fibrillation (AF) in a vast majority of cases. However, ectopic foci also exist in the non‐PV areas like superior vena cava (SVC) in 10–20% of the cases. We report the significance of SVC isolation in a patient with persistent AF and anomalous pulmonary venous connection of the right superior pulmonary vein into the SVC. (PACE 2013; 36:e146–e149)     

纵隔肿瘤的外科治疗体会

目的 总结纵隔肿瘤的诊断和外科治疗体会。方法 回顾分析139例纵隔肿瘤的手术方法及术后并发症的处理，手术方法包括单纯肿瘤切除，胸腺肿瘤切除合并纵隔脂肪扩大清除术，肿瘤侵犯肺叶楔形切除或肺叶切除术，上腔静脉置换术及无名静脉和上腔静脉成形术。结果 全组无死亡病例，术后复张性肺水肿3例，乳糜胸1例，肌无力危象5例，胆碱能危象1例，左无名静脉成形术后栓塞1例。结论 正确的围术期处理和手术方式的选择，可以提高纵隔纵隔肿瘤的治疗效果。     

Defibrillator Implantation in a Patient with a Persistent Left Superior Vena Cava

The implantation of a transvenous cardioverter defibrillator (PCD 7217B) was performed in a patient with a persistent left superior vena cava. The defibrillation electrodes were positioned in the right ventricle and the superior vena cava via the right subclavian vein. A subcutaneous patch had to be implanted at the left lateral chest wall to achieve sufficient defibrillation thresholds. Three weeks later the system had to be removed because of a generator pocket infection. During the second implantation we placed one electrode in the persistent left superior vena cava perpendicular to the electrode in the right ventricle. Using this configuration transvenous defibrillation was possible without an additional subcutaneous patch.     

Strategy of pacemaker and electrode replacement for superior vena cava stenosis

Cardiac implantable devices are commonly used for superior vena cava stenosis, but there have been few reports of electrode replacement in the stenosed superior vena cava. A 73-year-old man was diagnosed with second-degree type II atrioventricular block and a permanent dual-chamber, rate-modulated pacing pacemaker was implanted 10 years previously. Because of depletion of the pacemaker battery and an increase in the ventricular pacing threshold, replacement of the pacemaker and ventricular electrode was required. During the operation, we found that the patient had severe superior vena cava stenosis on angiography, and this caused obstruction when a common guidewire was used to pass through the superior vena cava. After attempting various methods, we successfully passed through the vascular stenosis with a super slide guidewire and a long sheath, and completed replacement of the pacemaker and ventricular electrode. We summarize the related literature of superior vena cava stenosis related to a cardiac implantable device, and discuss the replacement strategy of this complication and other treatment options.     

Implantable intravascular defibrillator: evaluation of defibrillation waveforms with inferior vena cava electrode system

Background: A percutaneously placed, totally intravascular defibrillator has been developed that shocks via a right ventricular (RV) single‐coil and titanium electrodes in the superior vena cava (SVC) and the inferior vena cava (IVC). This study evaluated the defibrillation threshold (DFT) with this electrode configuration to determine the effect of different biphasic waveform tilts and second‐phase durations as well as the contribution of the IVC electrode. Methods: Eight Bluetick hounds (wt = 30–40 kg) were anesthetized and the RV coil (first‐phase anode) was placed in the RV apex. The intravascular defibrillator (PICD^®, Model no. IIDM‐G, InnerPulse Inc., Research Triangle Park, NC, USA) was positioned such that the titanium electrodes were in the SVC and IVC . Ventricular fibrillation was electrically induced and a Bayesian up‐down technique was employed to determine DFT with two configurations: RV to SVC + IVC and RV to SVC. Three waveform tilts (65%, 50%, and 42%) and two second‐phase durations (equal to the first phase [balanced] and truncated at 3 ms [unbalanced]) were randomly tested. The source capacitance of the defibrillator was 120 μF for all waveforms. Results: DFT with the IVC electrode was significantly lower than without the IVC electrode for all waveforms tested (527 ± 9.3 V [standard error], 14.5 J vs 591 ± 7.4 V, 18.5 J, P < 0.001). Neither waveform tilt nor second‐phase duration significantly changed the DFT. Conclusion: In canines, a totally intravascular implantable defibrillator with electrodes in the RV apex, SVC, and IVC had a DFT similar to that of standard nonthoracotomy lead systems. No significant effect was noted with changes in tilt or with balanced or unbalanced waveforms. (PACE 2011; 34:577–583)     

Problems Encountered during Insertion of Permanent Endocardial Pacing Electrode

Case reports of two potential problems arising during permanent endocardial pacemaker electrode insertion are described. They are cannulation of a persistent left-sided superior vena cava, and unsuspected subclavian vein thrombosis. A left-sided superior vena cava may be recognized clinically and avoided; but, if necessary, it can be employed as a route to the right ventricular endocardium. Subclavian vein thrombosis appears to be a complication of previous cephalic vein pacemaker insertion and prohibits further access on the implanted side. It may present with a painful, swollen arm or with the symptoms of multiple pulmonary emboli; occasionally it is not clinically suspected unless abnormal venous distension is sought.     

The concentration of oxygen,lactate and glucose in the central veins,right heart,and pulmonary artery: a study in patients with pulmonary hypertension

Introduction  

Decreases in oxygen saturation (SO₂) and lactate concentration [Lac] from superior vena cava (SVC) to pulmonary artery have been reported. These gradients (ΔSO₂ and Δ[Lac]) are probably created by diluting SVC blood with blood of lower SO₂ and [Lac]. We tested the hypothesis that ΔSO₂ and Δ[Lac] result from mixing SVC and inferior vena cava (IVC) blood streams.     

Pacemaker Electrode Repositioning Using the Loop-Snare Technique

Using a percutaneous femoral vein approach under fluoroscopic control, a malpositioned ventricular pacemaker electrode was released from the right ventricular wall by hooking the lead with a deflecting wire inserted into a RIM catheter. A closed loop was formed by tightening the handle of the wire allowing the electrode to be dislodged and pulled into the inferior vena cava. The electrode was then snared using a loop formed by an exchange wire advanced through an 8 French catheter with a J-curve steamed at its tip. The electrode was advanced to the right ventricular apex and released by advancing one end of the snare wire while pulling the other end to open the loop.