PMC5419764_01
A: Negative deflections in II, III, and aVF (inferior leads) and positive deflections in V1 (criteria for flutter) suggesting cavotricuspid isthmus-dependent atrial flutter. B: Left internal jugular and left subclavian veins were the final access points still available, and losing this access was undesirable. C: Postprocedure electrocardiogram, which illustrates the termination of atrial flutter.
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American female patient with a past medical history of hypertension, congestive heart failure, paroxysmal atrial fibrillation, mitral regurgitation, and end-stage renal disease on renal replacement therapy (hemodialysis for 11 years) presented with normal sinus rhythm at the beginning of her dialysis session. After she developed symptoms of chest pain, dyspnea, and palpitations 1.5 hours into the dialysis session, she was transferred to a tertiary care center. Atrial flutter was noted on a 12-lead electrocardiogram (Figure 1A). On clinical examination, a 2/6 systolic murmur was heard, and a nonfunctioning left upper-extremity fistula was observed (Figure 1B). The patient had no episodes of bleeding, and she remained in sinus rhythm throughout the rest of her hospital stay (Figure 1C).
A: Placement of a second sheath with a 0.018 wire through a 22-gauge Chiba needle placed into a superficial hepatic vein via Doppler ultrasound and guided into the IVC. B: Coils being placed to prevent bleeding complications. C: 9F and 7F sheaths were placed into the right hepatic vein and middle hepatic vein, respectively, and advanced, as seen, with contrast to the right atrial junction. D: Two coils were placed to prevent peritoneal bleeding. IVC = inferior vena cava.
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Two catheters were used, and they were placed in the coronary sinus and on the cavotricuspid isthmus for ablation (Figures 2A-2C, Video 2). Postprocedure, sheaths were removed by vascular interventional radiology with coil embolization of the tracts (Figure 2D).