Key result
Pulsed-field ablation successfully treats SVC focal atrial tachycardia while sparing phrenic and sinus node function.
Why the study?
Right phrenic nerve injury is a major complication of thermal ablation of atrial tachycardias originating from the superior vena cava.
Does pulsed-field ablation safely and effectively eliminate focal atrial tachycardia originating from the superior vena cava near the phrenic nerve in a patient resistant to antiarrhythmic drugs?
Case Report (n=1)
No
Does pulsed-field ablation safely and effectively eliminate focal atrial tachycardia originating from the superior vena cava near the phrenic nerve in a patient resistant to antiarrhythmic drugs?
Pulsed-field ablation is a feasible and safe non-thermal approach to eliminate focal atrial tachycardia originating from the superior vena cava, allowing targeted ablation while avoiding collateral thermal injury to the right phrenic nerve.
Answers are grounded in this paper and cite their sources.
May support PFA for phrenic-adjacent SVC tachycardia; hypothesis-generating case report requiring prospective validation.
Background: Right phrenic nerve (PN) injury is a major complication of thermal ablation of atrial tachycardias (ATs) originated from the superior vena cava (SVC). Case summary: We report the case of a 41-year-old female patient admitted for catheter ablation of a frequent paroxysmal AT resistant to antiarrhythmic drugs. Electroanatomical activation map demonstrated a focal origin located at the lateral aspect of the SVC, ∼17 mm above the breakthrough of the sinus node wavefront. Importantly, high-output pacing from this site resulted in PN capture. To avoid PN injury, low-output radiofrequency (RF) ablation, with a power output limited to 20 W, was performed. However, this approach was insufficient to terminate AT. High-power RF applications in proximity to the PN were avoided and pulsed-field ablation (PFA) with a pentaspline catheter was chosen. The catheter was advanced into the SVC to the level of the earliest activation under fluoroscopic guidance and visualization within the mapping system. Two pairs of applications, in basket configuration, were delivered inside the SVC, rendering AT non-inducible while sinus node function was not compromised. Discussion: Phrenic nerve is vulnerable to injury during ablation within the SVC using thermal ablation modalities. Low-output RF ablation may be safe but less efficient. In contrast, non-thermal approaches such as PFA may be preferable to avoid damage to the collateral tissues as PN. Electroanatomical mapping may be important to avoid lesions in proximity to the sinus node.
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Tampakis et al. (2025) conducted a case report in Focal atrial tachycardia from the superior vena cava (n=1). Pulsed-field ablation (PFA) was evaluated on Atrial tachycardia non-inducibility and absence of phrenic nerve injury. Pulsed-field ablation using a pentaspline catheter successfully rendered focal atrial tachycardia from the superior vena cava non-inducible without compromising right phrenic nerve or sinus node function.
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