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Reasons for lack of femoral venous access for interventional procedures has been documented in the literature. Reasons include such conditions as chronic venous occlusions and venous malformations seen in heterotaxy syndrome. Heterotaxy syndrome is a rare congenital disease in which the internal thoracoabdominal organs demonstrate abnormal arrangement across the left–right axis of the body. The relationship of heterotaxy syndrome and atrial fibrillation has been documented, with prior incidence estimated at 23% of patients. A common feature of this syndrome is interruption of the inferior vena cava (IVC) with hemiazygos continuation into the superior vena cava (SVC). In either case, ablation via the internal jugular cannulation has been described, but it is technically suboptimal due to lack of support mainly from the inferior rim of the fossa ovalis. Hepatic vein cannulation has been used to obtain longterm access in various clinical scenarios, including hemodialysis and chemotherapy, with a complication rate of up to 5% reported for this approach in the pediatric population. In recent years, hepatic vein access has been reported in rare cases as a viable strategy for left-sided ablations. In this paper, we describe 3 cases of pulmonary vein isolation (PVI) in patients with interrupted IVCs necessitating hepatic vein access for ablation.

Hepatic vein access for pulmonary vein isolation in patients without femoral vein access