Radiofrequency catheter ablation of atrioventricular nodal reentry tachycardia: selective approach to the slow pathway via the superior vena cava

Selective radiofrequency catheter ablation of the slow atrioventricular nodal pathway is currently considered the first-line therapy for patients suffering from recurrent symptomatic atrioventricular nodal reentry tachycardia. In most cases slow pathway conduction may be selectively eliminated or modified by the application of radiofrequency current at the posterior portion of Koch's triangle. The ablation site is usually targeted by careful mapping of this area performed using an ablation catheter advanced via the inferior vena cava approach. In this report we describe 2 cases in which the conventional approach to the target site was either impossible owing to the presence of an atresic inferior vena cava (case 1), or contraindicated in view of a history of common femoral vein thrombosis, subsequently extended up to the inferior vena cava (case 2). In both patients a superior vena cava approach was utilized and the slow pathway was successfully ablated. In case of arrhythmias necessitating slow pathway mapping and ablation, such an approach may be considered as a feasible and safe alternative whenever, owing to the presence of anomalies and/or disease of the inferior vena cava, the conventional approach cannot be employed.