Techniques and outcomes of atrial fibrillation ablation in patients with persistent left superior vena cava

OBJECTIVES: To investigate tailored approaches, techniques, and outcomes of catheter ablation in patients with persistent left superior vena cava (PLSVC) undergoing atrial fibrillation (AF) ablation. BACKGROUND: PLSVC presents unique challenges for AF ablation due to its potential as an arrhythmogenic source and the complex anatomical variations it introduces. METHODS: The retrospective cohort included 16 patients with PLSVC that underwent 21 AF ablation procedures between August 1, 2008, and February 14, 2024, at the Hospital of the University of Pennsylvania. Procedures involved pre-ablation imaging, 3D electroanatomical mapping, pulmonary vein isolation, and targeted ablation strategies focusing on the PLSVC-related ablation. The primary endpoints were procedural safety and AF recurrence postablation. RESULTS: The cohort's mean age was 51.9 ± 17.9 years, 31.2% of whom were female. Triggers from the PLSVC were identified in 66.7% of procedures. Tailored ablation strategies were employed to isolate PLSVC-left atrium/coronary sinus connections or directly target the induced triggers, with a success rate of 85% in achieving isolation or targeted ablation once triggers were induced. The recurrence rate of arrhythmia postablation was 46.7% in the patient-based analysis and 65% in the procedure-based analysis. No major complications occurred. CONCLUSION: This study highlights the significance of recognizing PLSVC as a potential source of AF triggers. The single procedure success rate is low compared to patients without PLSVC. Further studies are warranted to enhance outcomes in this challenging AF population.