Catheter ablation of typical atrial flutter with the superior approach in a patient with inferior vena cava interruption

Figure 1. (Panel A) Twelve lead preprocedural ECG demonstrating typical counterclockwise atrial flutter with negative sawtooth F waves in the inferior leads. Panels B and C. Fluoroscopic catheter position in 45° left anterior oblique projection (Panel B) and in 30° right anterior oblique projection (Panel C). A duodecapolar catheter with its proximal five bipoles into the CS. The five proximal bipoles are positioned at the lateral tricuspid annulus. Ablation catheter is at the cavotricuspid isthmus. (Panel D) Surface ECG leads I, II, and V1 and intracardiac electrograms from the coronary sinus, lateral tricuspid annulus, and the ablation catheter at the cavotricuspid isthmus demonstrating atrial flutter termination during radiofrequency application at the cavotricuspid isthmus. Abl, ablation catheter positioned at the cavotricuspid isthmus; CS, coronary sinus; Halo, bipoles positioned at the lateral tricuspid annulus. Sweep speed: 25 mm/sec for panel A and 50 mm/sec for panel C.

Figure 2. Three‐dimensional volume rendering of the venous angiography presented in shallow left anterior oblique projection. IVC is absent in its inferior segments. There are well‐developed intra‐abdominal collaterals (arrowheads). The blood from the inferior parts of the body is drained via the paravertebral veins and the intra‐abdominal collaterals to the dilated azygos vein (arrow).