Pulsed-Field Ablation With a Persistent Left Superior Vena Cava

BACKGROUND: A persistent left superior vena cava (PLSVC) is an important source of nonpulmonary vein triggers in patients with atrial fibrillation. However, experience with pulsed-field ablation (PFA) in the presence of a PLSVC is limited. CASE SUMMARY: A 63-year-old man with persistent atrial fibrillation presented for PFA. A previously unrecognized PLSVC was identified. A decapolar catheter was positioned in the PLSVC. During PFA, attenuation of the PLSVC electrograms was observed, consistent with a potentially transmural effect. Given this observation and the lack of preprocedural discussion with the patient, direct ablation within the PLSVC was not undertaken. DISCUSSION: Our case suggests that PFA within the left atrium may affect the adjacent PLSVC and potentially eliminate PLSVC triggers and PLSVC-left atrial connections. TAKE-HOME MESSAGE: PFA lesions within the left atrium may extend in part transmurally to the adjacent PLSVC, potentially obviating the need for direct ablation within the PLSVC and associated risks.