This method has been recently proposed, in which SVCI is prophylactically performed in addition to PVI. Corrado et al. demonstrated in their randomized study that the patients who underwent SVCI as an adjunctive therapy to PVI had significantly lower recurrence rate of atrial fibrillation than those who underwent only PVI . Their 1-year success rate after an initial ablation procedure with PVI and PVI along with SVCI for paroxysmal atrial fibrillation patients was 77 vs. 90% (P = 0.04). On the contrary, Wang et al. also conducted a randomized prospective study comparing the beneficial difference between two strategies, PVI and empiric PVI along with SVCI for patients with paroxysmal atrial fibrillation. In this study, they did not find statistical significance between these two strategies regarding the success rate 1 year after initial atrial fibrillation ablation (PVI, 81%; PVI along with SVCI, 86%; P = 0.75).
Because of the proximity of SVC-aorta ganglionated plexi to the SVC and the good extension of myocardium in the SVC from the RA, SVC frequently becomes an important source of ectopic beats initiating atrial fibrillation. Therefore, SVC should be carefully examined, whether it has an arrhythmogenicity or not, in order to reduce the recurrence of atrial fibrillation. Performing SVCI only if SVC triggers are recognized after pacing maneuvers and/or isoproterenol infusions seems to be reasonable in order to avoid unnecessary ablations and complications.
Papers of particular interest, published within the annual period of review, have been highlighted as:
Additional references related to this topic can also be found in the Current World Literature section in this issue (p. 80).
1. Fuster V, Ryden LE, Cannom DS, et al. 2011 ACCF/AHA/HRS focused updates incorporated into the ACC/AHA/ESC 2006 Guidelines for the management of patients with atrial fibrillation
: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines developed in partnership with the European Society of Cardiology and in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society. J Am Coll Cardiol 2011; 57:e101–e198.
2. Haïssaguerre M, Jaïs P, Shah DC, et al. Spontaneous initiation of atrial fibrillation
by ectopic beats originating in the pulmonary veins. New Engl J Med 1998; 339:659–666.
3. Lin WS, Tai CT, Hsieh MH, et al. Catheter ablation
of paroxysmal atrial fibrillation
initiated by nonpulmonary vein ectopy. Circulation 2003; 107:3176–3183.
4. Yamaguchi T, Tsuchiya T, Miyamoto K, et al. Characterization of nonpulmonary vein foci with an EnSite array in patients with paroxysmal atrial fibrillation
. Europace 2010; 12:1698–1706.
5. Arruda M, Mlcochova H, Prasad SK, et al. Electrical isolation
of the superior vena cava
: an adjunctive strategy to pulmonary vein antrum isolation improving the outcome of AF ablation. J Cardiovasc Electrophysiol 2007; 18:1261–1266.
6. Corrado A, Bonso A, Madalosso M, et al. Impact of systematic isolation of superior vena cava
in addition to pulmonary vein antrum isolation on the outcome of paroxysmal, persistent, and permanent atrial fibrillation
ablation: results from a randomized study. J Cardiovasc Electrophysiol 2010; 21:1–5.
7. Ghias M, Scherlag BJ, Lu Z, et al. The role of ganglionated plexi in apnea-related atrial fibrillation
. J Am Coll Cardiol 2009; 54:2075–2083.
8. Tsai CF, Tai CT, Hsieh MH, et al. Initiation of atrial fibrillation
by ectopic beats originating from the superior vena cava
: electrophysiological characteristics and results of radiofrequency ablation. Circulation 2000; 102:67–74.
9. Higuchi K, Yamauchi Y, Hirao K, et al. Superior vena cava
as initiator of atrial fibrillation
: factors related to its arrhythmogenicity. Heart Rhythm 2010; 7:1186–1191.
10▪▪. Sicouri S, Blazek J, Belardinelli L, Antzelevitch C. Electrophysiological characteristics of canine superior vena cava
sleeve preparations: effect of ranolazine. Circ Arrhythm Electrophysiol 2012; 5:371–379.
This animal study demonstrated autonomic influences in promoting spontaneous automaticity and triggered activity in SVC sleeves. Automaticity and triggered activity generated extrasystolic activity in SVC sleeves and initiated atrial fibrillation.
11. Chiou CW, Eble JN, Zipes DP. Efferent vagal innervation of the canine atria and sinus and atrioventricular nodes. The third fat pad. Circulation 1997; 95:2573–2584.
12. Lu Z, Scherlag BJ, Niu G, et al. Functional properties of the superior vena cava
(SVC)-aorta ganglionated plexus: evidence suggesting an autonomic basis for rapid SVC firing. J Cardiovasc Electrophysiol 2010; 21:1392–1399.
13. Hashizume H, Ushiki T, Abe K. A histological study of the cardiac muscle of the human superior and inferior venae cavae. Arch Histol Cytol 1995; 58:457–464.
14. Kholova I, Kautzner J. Morphology of atrial myocardial extensions into human caval veins: a postmortem study in patients with and without atrial fibrillation
. Circulation 2004; 110:483–488.
15▪▪. Chang HY, Lo LW, Lin YJ, et al.
Long-term outcome of catheter ablation
in patients with atrial fibrillation
originating from the superior vena cava
. J Cardiovasc Electrophysiol 2012; 23:955–961.
This is the first report about long-term outcomes of catheter ablation in patients with atrial fibrillation from SVC origin. The atrial fibrillation freedom rate 5 years after initial ablation was 73.3%.
16. Goya M, Ouyang F, Ernst S, et al. Electroanatomic mapping and catheter ablation
of breakthroughs from the right atrium to the superior vena cava
in patients with atrial fibrillation
. Circulation 2002; 106:1317–1320.
17. Fenelon G, Franco M, Arfelli E, et al. Acute and chronic effects of extensive radiofrequency lesions in the canine caval veins: implications for ablation of atrial arrhythmias. PACE 2006; 29:1387–1394.
18. Kuhne M, Schaer B, Osswald S, Sticherling C. Superior vena cava
stenosis after radiofrequency catheter ablation
for electrical isolation
of the superior vena cava
. PACE 2010; 33:e36–e38.
19▪. Chen G, Dong JZ, Liu XP, et al. Sinus node injury as a result of superior vena cava
isolation during catheter ablation
for atrial fibrillation
and atrial flutter. PACE 2011; 34:163–170.
Sinus node injury is a complication after SVC isolation, which occurred in 4.5% of this study cohort. This study reports characteristics of sinus node dysfunction after SVC isolation.
20. Akoum N, McGann C, Vergara G, et al. Atrial fibrosis quantified using late gadolinium enhancement MRI is associated with sinus node dysfunction requiring pacemaker implant. J Cardiovasc Electrophysiol 2012; 23:44–50.
21. Bai R, Patel D, Di Biase L, et al. Phrenic nerve injury after catheter ablation
: should we worry about this complication? J Cardiovasc Electrophysiol 2006; 17:944–948.
22. Wang XH, Liu X, Sun YM, et al. Pulmonary vein isolation combined with superior vena cava
isolation for atrial fibrillation
ablation: a prospective randomized study. Europace 2008; 10:600–605.