Vol.2, No.8, 445-447 (2013) Case Reports in Clinical Medicine
Successful left-sided accessory pathway ablation
without reference catheter in patient with atresia of
coronary sinus and thin persistent left superior
vena cava*
Qingxing Chen, Ye Xu, Kuang Cheng, Wenqing Zhu#
Department of Cardiology, Zhongshan Hospital, The Shanghai Institute of Cardiovascular Diseases, Fudan University, Shanghai,
China; #Corresponding Author: zhu.wenqing@zs-hospital.sh.cn
Received 7 September 2013; revised 1 October 2013; accepted 29 October 2013
Copyright © 2013 Qingxing Chen et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
We report a case of atrioventricular reentrant
tachycardia (AVRT) with ostial atresia of the
coronary sinus (CS). Without the anatomic an-
giography, radiofrequency (RF) energy was ap-
plied at the mitral valve annulus and the bypass
tract was eliminated. After the therapy proce-
dure, by CS angiography, we knew the persis-
tent left superior vena cava (PLSVC), and the
coronary sinus was connected with vena cava
superior, very thin in a diameter. The therapy
procedure was successful. The patient has re-
mained completely symptom free.
Keyw ords: Ablation; Accessory Pathway; Atresia of
the Coronary Sinus
Coronary sinus (CS) atresia is a rare cardiac anatomic
variant which causes failure to cannulate CS and consid-
erable challenges in affecting cure. CS ostial atresia was
associated with a few persistent left superior vena cavas
(PLSVC), an unroofed coronary sinus, or was a postop-
erative complication [1-5]. Patients with CS ostial atresia
have been reported to have atrioventricular reentrant
tachycardia [3-5], atrial flutter [4], and atrioventricular
nodal reentrant tachycardia [6].
We report a case of CS ostial atresia with anomalous
venous drainage into PLSVC with a left-sided accessory
pathway (AP) that was successfully eliminated by cathe-
ter ablation.
A 57-year-old man with recurrent paroxysmal su-
praventricular tachycardia (PSVT) effective to propa-
fenone was referred to our hospital for a cardiac electro-
physiologicstudy (EPS) and ablation one month ago. A
12-lead electrocardiogram (ECG) done during sinus
rhythm exhibited no delta waves. A 12-lead ECG done
during the palpitation revealed a regular, narrow QRS
tachycardia at a rate of 170 bpm with P’-waves in leads
II and aVF, QRS-P’ interval was 86ms; this suggested
that the patient had an atrioventricular reentrant tachy-
cardia (AVRT) through a concealed accessory pathway
(AP). The physical examination, chest x-ray, echocar-
diograms and serological examinations were normal.
After written informed consent was obtained from the
patient, EPS was done after the withdrawal of all antiar-
rhythmic drugs for five elimination half-lives.
One quadripolar electrode catheter was cannulated
from Vena cava inferior, positioned in the right ventricu-
lar apex. One multipolar electrode catheter was cannu-
lated from Subclavian Vein. Attempts to cannulate the
coronary sinus (CS) were unsuccessful. Without CS an-
giography, we set a proximal electrode of multipolar
catheter on the ostial of CS.
Baseline intervals during sinus were as follows: sinus
cycle length 660 ms, atrial His (AH) interval 79 ms, and
His-ventricular (HV) interval 64 ms. There was no ven-
tricular preexcitation during sinus rhythm and decre-
mental ventricular pacing down to 350 ms. A regular,
narrow QRS tachycardia with a cycle length of 350 ms
was repeatly induced. During tachycardia, proximal mul-
tipolar electrode was revealed V-A interval 86 ms, mid-
dle electrode was revealed V-A interval 145 ms, distal
*Conflict of Interest: None.
Copyright © 2013 SciRes. OPEN A CCESS
Q. X. Chen et al. / Case Reports in Clinical Medicine 2 (2013) 445-447
electrode couldn’t recorded ventricular potential. Ven-
tricular-atrial transmits are at the same rhythm. This sug-
gested the tachycardia was orthodromic atrioventricular
reentrant tachycardia (OAVRT) with a concealed left-
sided AP.
Mapping of the mitral valve annulus was performed
during ventricular pacing, using a Medtronic ablation
catheter with a 4-mm distal tip that was inserted from the
right femoral artery. The earliest activated point on atrial
side was recorded in the 3 o’clock region of the mitral
annulus. Radiofrequency (RF) energy, delivered to this
site for 240 seconds at a temperature of 60˚C, eliminated
the bypass tract. Fifteen minutes after the delivery of the
RF energy, there was persistent ventricularatrial (VA)
dissociation. At present, the patient had remained com-
pletely symptom-free.
CS angiography was done after the RF. It revealed that
ostium atresia of CS and CS was connected with anoma-
lous venous drainage into persistent left superior vena
cavas (PLSVC), very thin i n diameter (Figure 1).
We performed a catheter ablation of a left-sided AV
bypass tract in a patient with ostial atresia of CS. The
previously reported cases of CS ostial atresia were asso-
ciated with a few persistent left superior vena cavas
(PLSV C), an unroofed CS, or were a posto perative com-
plication [1-5]. Patients with CS ostial atresia have been
repor ted to have AVRT[3-5], atrial flutter [4] and atrioven-
tricular nodal reentrant tachycardia (AVNRT) [6]. In all the
reported cases, we found that left-sided AP is in the major-
The recognition of this anomaly is important for at
least two re asons. First, i t might prevent fu tile attemp ts
to access the CS conventionally which might lead to
prolonged x-ray exposure and serious complications
such as cardiac perforation. If the patient was suffering
from the AVNRT, lesion of slow pathway region would
be familiar. Second, in the presence of this anomaly,
particularly the PLSVC may be arrhythmogenic due to
its intricate relation with the ligament of Marshall and
a dilated CS [7]. Both conditions are known to favor
arrhythmogenesis. So, in our patients, recording poten-
tial or pacing mapping from the PLSVC or CS was
important. After the ablation, the PLSVC and CS were
cannulated, and extraordinary potential has not been
Cathe ter ab la t ion o f a le f t fr ee -wal l A P is usuall y p er-
formed under the guidance of a reference electrode,
though ablation without a reference catheter has been
reported in a few experienced centers [8,9]. In our pa-
tient, the placement of a multipolar electrode catheter
only revealed the position of the ostial of CS. By endo-
cardial mapping of the multipolar electrode, we knew
the AVRT came of a left-sided AP. Without a reference
catheter, mapping of the mitral valve annulus couldn’t
be accurate. So, experience of the operator was more
Figure 1. Coronary angiography after successfully ablation. (Left) Ablation catheter had been evacuated. Distal electrode of multi-
polar catheter was positioned on the ostial of the coronary sinus (CS). Coronary angiography showed ostium atresia of coronary
sinus (CS). (Right) coronary sinus (CS) was connect with anomalous venous drainage into left-persistent vena cava superior
(L-PVCS), very thin in diameter.
Copyright © 2013 SciRes. OPEN A CCESS
Q. X. Chen et al. / Case Reports in Clinical Medicine 2 (2013) 445-447 447
In conclusion, we report a case of CS ostial atresia
with anomalous venous drainage into PLSVC with a
left-sided AP that was successfully eliminated by catheter
[1] Santoscoy, R., Walters, H.L., Ross, R.D., Lyons, J.M. and
Hakimi, M. (1996) Coronary sinus ostial atresia with per-
sistent left superior vena cava. The Annals of Thoracic
Surgery, 61, 879-882.
[2] Adatia, I. and de Gittenberger-de Groot, A.C. (1995) Un-
roofed coronary sinus and coronary sinus orice atresia.
Implications for management of complex congenital heart
disease. American College of Cardiology, 25, 948-953.
[3] Takatsuki, S., Mitamura, H., Ieda, M. and Ogawa, S.
(2001) Accessory pathway associated with an anomalous
coronary vein in a patient with Wolff-Parkinson-White
syndrome. Journal of Cardiovascular Electrophysiology,
12, 1080-1082.
[4] Luik, A., Deisenhofer, I., Estner, H., Ndrepepa, P.A.,
Zrenner, B. and Schmitt, C. (2006) Atresia of the coro-
nary sinus in patients with supraventricular tachycardia.
Pacing and Clinical Electrophysiology, 29, 171-174.
http://dx.doi.or g/10.1111/j.1540-8159.2006.00312.x
[5] Khairy, P., Triedman, J.K., Juraszek, A. and Cecchin, F.
(2005) Inability to cannulate the coronary sinus in pa-
tients with supraventricular arrhythmias: Congenital and
acquired coronary sinus atresia. Journal of Interventional
Cardiac Electrophysiology, 12, 123-127.
[6] Okuyama, Y., Oka, T., Mizuno, H., Sakai, T., Hirayama,
A. and Kodama, K. (2005) A case of atrioventricular
nodal reentrant tachycardia with atresia of the coronary
sinus ostium. International Heart Journal, 46, 899-902.
[7] Jah, N.K., Gogna, A., Tan, T.H., Wong, K.Y. and Shankar,
S. (2003) Atresia of coronary sinus with retrograde drain-
age via persistent left superior vena cava. The Annals of
Thoracic Surgery, 76, 2091-2092.
[8] Kuck, K.H. and Schluter, M. (1991) Single-catheter ap-
proach to radiofrequency current ablation of left-sided
accessory pathways in patients with Wolff-Parkinson-
White syndrome. Circulation, 84, 2366-2375.
[9] Brugada, J., Garcia -Bola o, I. , Figue ire do, M., Puigfe l, M.,
Matas, M. and Navarro-Lopez, F. (1997) Radiofrequency
ablation of concealed left free wall accessory pathways
without coronary sinus catheterization: Results in 100
consecutive patients. Journal of Cardiovascular Electro-
physiology, 8, 249-253.
http://dx.doi.or g/10.1111/j.1540-8167.1997.tb00787.x
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