Pulmonary vein isolation combined with superior vena
cava isolation for atrial fibrillation ablation: a
prospective randomized study
Xin-Hua Wang, Xu Liu*, Yu-Min Sun, Hai-Feng Shi, Li Zhou, and Jia-Ning Gu
Department of Cardiology, Shanghai Chest Hospital Affiliated to Shanghai Jiaotong University, Shanghai 200030, People’s
Republic of China
Received 21 December 2007; accepted after revision 10 March 2008
Aims Circumferential pulmonary vein isolation (CPVI) is an established strategy for atrial fibrillation
(AF) ablation. Superior vena cava (SVC), by harbouring the majority of non-pulmonary vein
(PV) foci, is the most common non-PV origin for AF. However, it is unknown whether CPVI com-
bined with SVC isolation (SVCI) could improve clinical results and whether SVCI is technically safe and
Methods and results A total of 106 cases (58 males, average age 66.0+8.8 years) with paroxysmal AF
were included for ablation. They were allocated randomly to two groups: CPVI group (n ¼ 54) and
CPVI þ SVCI group (n ¼ 52). All cases underwent the procedure successfully. Pulmonary vein isolation
was achieved in all cases. The procedural time and fluoroscopic time were comparable between the
two groups. The mean ablation time for SVC was 7.8+2.7 min. Superior vena cava isolation was
obtained in 50/52 cases. In the remaining two cases, SVCI was not achieved because of obviating dia-
phragmatic nerve injury. During a mean follow-up of 4+2 months, 12 (22.2%) cases in the CPVI
group and 10 (19.2%) cases in the CPVI þ SVCI group had atrial tachyarrhythmias (ATa) recurrence
(P ¼ 0.70). Nine of 12 cases in the CPVI group and 8/10 cases in the CPVI þ SVCI group underwent rea-
blation (P ¼ 0.86), and PV reconnection occurred in 7/9 cases in the CPVI group and in 8/8 cases in the
CPVI þ SVCI group. All PV reconnection was reisolated by gaps ablation. There was no SVC reconnection
in the CPVI þ SVCI group. In two cases without PV reconnection from the CPVI group, SVC-originated
short run of atrial tachycardia was identified and eliminated by the SVCI. At the end of 12 months of
follow-up, 50 cases (92.6%) in the CPVI group and 49 (94.2%) in the CPVI þ SVC group were free of
ATa recurrence (P ¼ 0.73).
Conclusion In our series of paroxysmal AF patients, empirically adding SVCI to CPVI did not significantly
reduce the AF recurrence after ablation. Superior vena cava isolation may be useful, however, in
selected patients in whom the SVC is identified as a trigger for AF. However, because of the preliminary
property of the study and its relatively small sample size, the impact of SVCI on clinical results should be
evaluated in a large series of patients.
Superior vena cava
Ectopic foci arising from pulmonary veins (PVs) are the pre-
dominant sources for the initiation and maintenance of
atrial fibrillation (AF) in a vast majority of cases.1,2Pulmo-
nary vein isolation has therefore become the main strategy
for treating thisfrustrating arrhythmia.3,4
approach for PV isolation is circumferential PV isolation
(CPVI), which is performed at the PV antrum to encircle PV
foci.5,6However, further studies demonstrate that ectopic
foci also exist in the non-PVs areas in 10–20% of the cases
with paroxysmal AF,7–10such as superior vena cava (SVC),
coronary sinus (CS), inferior vena cava, ligament of Marshall,
and so on. Especially, SVC by harbouring 26–30% of the
non-PV foci becomes the most common non-PV origin for
AF.7This prospective study is carried out to explore
whether SVC isolation (SVCI) is feasible and safe and to
evaluate the effectiveness of adjunctive SVCI for AF therapy.
*Corresponding author. Tel: þ86 21 62821990 60605; fax: þ86 21
E-mail address: firstname.lastname@example.org
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Europace (2008) 10, 600–605
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number of patients required to be enrolled. Therefore, this
was a preliminary study and patient enrolment was open.
Owing to the relatively small sample size and the short
follow-up period of the study, we have not observed the
statistically significant difference regarding the success
rate between two groups. The exact role of SVCI on long-
term clinical results should be evaluated in large volume,
long follow-up period studies. 2. The success rate of ablation
might be overestimated as ATa recurrence was mainly
judged upon symptoms. Frequent ECG examination, 24 h
Holter monitoring every 2 months, and monthly telephone
inquiry did not exclude asymptomatic or short episode
In our series of paroxysmal AF patients, adjunctive SVCI does
not significantly improve the success rate of ablation,
although SVCI is necessary for eliminating SVC-originated
AF. Superior vena cava isolation is technically safe and feas-
ible. Owing to the preliminary property of the study and its
relatively small sample size, the impact of SVCI on clinical
results should be evaluated in a large series of patients.
Conflict of interest: none declared.
1. Haı ¨ssaguerre M, Jais P, Shah DC, Takahashi A, Hocini M, Quiniou G et al.
Spontaneous initiation of atrial fibrillation by ectopic beats originating in
the pulmonary veins. N Engl J Med 1998;339:659–666.
2. Chen SA, Hsieh MH, Tai CT, Tsai CF, Prakash VS, Yu WC et al. Initiation
of atrial fibrillation by ectopic beats originating from the pulmonary
veins: electrophysiological characteristics, pharmacological responses,
and effects of radiofrequency ablation. Circulation 1999;100:1879–1886.
3. Oral H, Scharf C, Chugh A, Hall B, Cheung P, Good E et al. Catheter abla-
tion for paroxysmal atrial fibrillation: segmental pulmonary vein ostial
ablation versus left atrial ablation. Circulation 2003;108:2355–2360.
4. Haı ¨ssaguerre M, Sanders P, Hocini M, Hsu LF, Shah DC, Scave ´e C et al.
Change in trial fibrillation cycle length and inducibility during catheter
ablation and their relation to outcome. Circulation 2004;109:3007–3013.
5. Ouyang F, Bansch D, Ernst S, Schaumann A, Hachiya H, Chen M et al. Com-
plete isolation of left atrium surrounding the pulmonary veins new
insights from the double Lasso technique in paroxysmal atrial fibrillation.
6. Ouyang F, Antz M, Ernst S, Hachiya H, Mavrakis H, Deger FT et al.
Recovered pulmonary vein conduction as a dominant factor for recurrent
atrial tachyarrhythmiasafter complete
pulmonary veins lessons from double Lasso technique. Circulation 2005;
7. Lin WS, Tai CT, Hsieh MH, Tsai CF, Lin YK, Tsao HM et al. Catheter ablation
of paroxysmal atrial fibrillation initiated by non-pulmonary vein ectopy.
circularisolation of the
8. Rostock T, Lutomsky B, Steven D, Willems S. The coronary sinus as a focal
source of paroxysmal atrial fibrillation: more evidence for the ‘fifth
pulmonary vein’? Pacing Clin Electrophysiol 2007;30:1027–1031.
9. Scavee C, Jais P, Weerasooriya R, Haı ¨ssaguerre M. The inferior vena cava:
10. Kurotobi T, Ito H, Inoue K, Iwakura K, Kawano S, Okamura A et al. Mar-
shall vein as arrhythmogenic source in patients with atrial fibrillation:
correlation between its anatomy and electrophysiological findings.
J Cardiovasc Electrophysiol 2006;7:1062–1067.
11. Wang XH, Liu X, Sun YM, Gu JN, Shi HF, Zhou L et al. Early identification
and treatment of PV re-connections: role of observation time and
impact on clinical results of atrial fibrillation ablation. Europace 2007;
12. Saito T, Waki K, Becker AE. Left atrial myocardial extension onto pulmon-
ary veins in humans: anatomic observations relevant for atrial arrhyth-
mias. J Cardiovasc Electrophysiol 2000;11:888–894.
13. Pappone C, Rosanio S, Oreto G, Tocchi M, Gugliotta F, Vicedomini G et al.
Circumferential radiofrequency ablation of pulmonary vein ostia a new
anatomic approach for curing atrial fibrillation. Circulation 2000;102:
14. Keller BB, Markwald RR. Embryology of the heart. In Alexander RW,
Schlant RC, Fuster V (eds). Hurst’s The Heart. New York: McGraw-Hill
1998 p. 205.
15. Spach MS, Barr RC, Jewett PH. Spread of excitation from the atrium into
thoracic veins in human beings and dogs. Am J Cardiol 1972;30:844–854.
16. Hashizume H, Ushiki T, Abe K. A histological study of the cardiac muscle
of the human superior and inferior venae cavae. Arch Histol Cytol 1995;
17. Ito M, Arita M, Saeki K, Tanoue M, Fukushima I. Functional properties of
sinocaval conduction. Jpn J Physiol 1967;17:174–189.
18. Chen SA, Chiang CE, Yang CJ, Cheng CC, Wu TJ, Wang SP et al. Sustained
atrial tachycardia in adult patients: electrophysiological characteristics,
pharmacological response, possible mechanisms, and effects of radiofre-
quency ablation. Circulation 1994;90:1262–1278.
19. Tsai CF, Tai CT, Hsieh MH, Lin WS, Yu WC, Ueng KC et al. Initiation of atrial
fibrillation by ectopic beats originating from the superior vena cava:
electrophysiological characteristics and results of radiofrequency abla-
tion. Circulation 2000;102:67–74.
20. Lee SH, Tai CT, Hsieh MH, Tsao HM, Lin YJ, Chang SL et al. Predictors of
non-pulmonary vein ectopic beats initiating paroxysmal atrial fibrillation:
implication for catheter ablation. J Am Coll Cardiol 2005;46:1054–1059.
21. Arruda M, Mlcochova H, Prasad SK, Kilicaslan F, Saliba W, Patel D et al.
Electrical isolation of the superior vena cava: An adjunctive strategy to
pulmonary vein antrum isolation improving the outcome of AF ablation.
J Cardiovasc Electrophysiol 2007;18:1261–1266.
22. Kholova ´ I, Kautzner J. Morphology of atrial myocardial extensions into
human caval veins: a postmortem study in patients with and without
atrial fibrillation. Circulation 2004;110:483–488.
23. Yeh HI, Lai YJ, Lee SH, Lee YN, Ko YS, Chen SA et al. Heterogeneity of
myocardial sleeve morphology and gap junctions in canine superior
vena cava. Circulation 2001;104:3152–3157.
24. Goya M, Ouyang F, Ernst S, Volkmer M, Antz M, Kuck KH. Electroanatomic
mapping and catheter ablation of breakthroughs from the right atrium to
the superior vena cava in patients with atrial fibrillation. Circulation
25. Chun KR, Bansch D, Ernst S, Ujeyl A, Huang H, Chu H et al. Pulmonary
vein conduction is the major finding in patients with atrial tachyarrhyth-
mias after intraoperative maze ablation. J Cardiovasc Electrophysiol
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