Atrial Tachycardia Arising from an Epicardial Site with Venous Connection Between the Left Superior Pulmonary Vein and Superior Vena Cava

We describe a case of atrial tachycardia originating from an epicardial site with a venous connection between the left superior pulmonary vein (LSPV) and superior vena cava (SVC). Initial endocardial mapping with multiple electrodes catheters demonstrated early endocardial activation at both the SVC and LSPV. However, radiofrequency applications at the SVC failed to terminate the atrial tachycardia. With three-dimensional electroanatomic mapping, the earliest endocardial activation was found to be in the left atrial appendage (LAA). However, radiofrequency energy applications at multiple sites in the LAA resulted in only transient termination of the tachycardia. A left atrial angiogram demonstrated a venous connection between the LSPV and SVC, overlying the LAA. An application of radiofrequency energy with a saline-irrigated ablation catheter delivered at the earliest activation site in the LAA terminated the tachycardia. The tachycardia did not recur during 18-month follow-up.