Complex electrophysiology intervention in a patient with an … · 2016. 12. 7. · Case report Complex electrophysiology intervention in a patient with an inferior vena cava filter

Case report

Complex electrophysiology intervention in a patientwith an inferior vena cava filter

Jiri Jez a,b,*, Zdenek Starek a,b, Frantisek Lehar a, Jiri Wolf a,b,Miroslav Novak a,b

aThe 1st Department of Internal Medicine – Cardioangiology, International Clinical Research Center/St. Anne'sUniversity Hospital Brno, Czech Republicb Faculty of Medicine, Masaryk University, Brno, Czech Republic

c o r e t v a s a 5 7 ( 2 0 1 5 ) e 3 4 1 – e 3 4 6

a r t i c l e i n f o

Article history:

Received 15 March 2015

Received in revised form

25 April 2015

Accepted 4 May 2015

Available online 1 June 2015

Keywords:

Inferior vena cava filter

Catheter ablation

Arrhythmia

Atrial flutter

a b s t r a c t

Catheter ablation is currently a routine clinical method for the treatment of heart rhythm

disorders. The presence of a filter in the lumen of the inferior vena cava represents a

mechanical obstruction that may complicate or contraindicate the procedure. Still, there is

not enough information available on this topic and there is no research data on the catheter

ablation of complex left atrial arrhythmias with a transseptal puncture in the presence of an

inferior vena cava filter. Our case report represents a successful complex electrophysiology

intervention in both the left and right atria with femoral venous access in a patient with an

inferior vena cava filter.

# 2015 The Czech Society of Cardiology. Published by Elsevier Sp. z o.o. All rights

reserved.

Available online at www.sciencedirect.com

ScienceDirect

journal homepage: http://www.elsevier.com/locate/crvasa

.

Introduction

Radiofrequency catheter ablation has become a routineclinical method in recent years and in many cases it is alsothe most effective treatment of arrhythmias. In less complexheart rhythm disorders it can be performed through thejugular or subclavian vein. However, the transfemoralapproach is preferred; it provides a minor risk of complica-tions, more flexibility and reduced radiation exposurefor physicians. It is also crucial for treating complexarrhythmias. Any abnormalities in the anatomy or barriers

* Corresponding author at : International Clinical Research Center/St. A Republic. Tel.: +420 543 182 187; fax: +420 543 182 205.

E-mail address: [email protected] (J. Jez).http://dx.doi.org/10.1016/j.crvasa.2015.05.0050010-8650/# 2015 The Czech Society of Cardiology. Published by Else

in the patency of veins can complicate or obviate theprocedure.

An IVC filter placement is a substitute method used in theprevention of pulmonary embolism. In our background, thedevice is used in only a small number of patients and itsefficacy and safety is still a matter of debate [1,2]. Concerningelectrophysiology intervention with the transfemoral ap-proach, only electrophysiology studies and catheter ablationin the right atrium were performed in these patients [3–6].Access through an IVC filter carries a high risk of complica-tions, such as the dislodgment of the filter or the entrapmentof guide wires [7–12]. Catheter ablation of complex arrhythmia

nne's University Hospital in Brno, Pekarska 53, 656 91 Brno, Czech

vier Sp. z All rights reserved..o.o.

http://crossmark.crossref.org/dialog/?doi=10.1016/j.crvasa.2015.05.005&domain=pdfhttp://crossmark.crossref.org/dialog/?doi=10.1016/j.crvasa.2015.05.005&domain=pdfhttp://dx.doi.org/10.1016/j.crvasa.2015.05.005mailto:[email protected]://www.sciencedirect.com/science/journal/00108650http://www.elsevier.com/locate/crvasahttp://dx.doi.org/10.1016/j.crvasa.2015.05.005

Fig. 1 – X-ray image showing transseptal sheaths passingthrough an IVC filter (Vena TechTM LP Cava Filter).

c o r e t v a s a 5 7 ( 2 0 1 5 ) e 3 4 1 – e 3 4 6e342

involving a transseptal puncture and intervention in severalheart chambers in a patient with an IVC filter is not routinelyperformed, which makes this procedure attractive. Such ademanding procedure requires the use of more guide wires,increases the risk of filter displacement or damage and alsomakes the time frame of the intervention longer, thusresulting in a greater risk of a thromboembolic complicationor bleeding.

Case report

A 70-year-old man with a history of thromboembolic diseasetreated by anticoagulant therapy had an IVC filter (VenaTechTM LP Cava Filter, B. Braun Interventional Systems Inc.)placement performed in 2000. After an electrophysiologystudy at our department in April 2011 (using a jugular andsubclavian vein approach), focal atrial tachycardia wasdiagnosed and the appropriate medication therapy wasrecommended. In March 2012, the patient underwent biopros-thetic aortic valve replacement and double aortocoronarybypass surgery and suffered from post-operative atrialfibrillation which was resolved by the administration ofamiodarone. Following the planned lower extremity vascularsurgery, a supraventricular tachycardia with a 2:1 block andventricular frequency around 130/min appeared and wasdiagnosed as atypical atrial flutter in June 2012. Electricalcardioversion restored the sinus rhythm and the medicationwas altered. In September 2012, the patient's conditionworsened, the recurrence of atypical atrial flutter was reportedand a complex electrophysiology procedure was stronglyrecommended.

Methods

After the patient's preparation the procedure was initiated by aright subclavian vein cannulation and a decapolar catheter(Inquiry, St. Jude Medical, Inc.) was inserted into the coronarysinus using a 7 Fr sheath. The femoral vein was punctured andtwo transseptal sheaths (SwartzTM FasthCath SL1, St. JudeMedical, Inc. (8F) and AgilisTM, St. Jude Medical, Inc. (8.5F)) wereplaced into the inferior vena cava (IVC) right below the IVCfilter. Angiography confirmed the patency of the filter andproved the absence of thrombus. Two straight guide wireswere used for the IVC filter crossing due to the potentialproblematic nature of J-tip guide wires [9–11]. The filter waspassed without any complications by the over wire method inthe anteroposterior projection under continuous fluoroscopicguidance (Fig. 1). Sheaths were placed just below the rightatrium. All major manipulation during the procedure wasmonitored by fluoroscopy. Atrial flutter of an averagefrequency of 250/min with the earliest activation at theinteratrial septum (IAS) was recorded by passing a duodeca-polar diagnostic catheter (HalloTM XP, Biosense Webster, Inc.) andan ablation catheter (Celsius ThermoCool F Type, BiosenseWebster, Inc.) into the right atrium through transseptalsheaths. Entrainment mapping detected a concealed entrain-ment with a short post-pacing interval (PPI) in the upper regionof the IAS; the remainder of the right atrium did not contribute

to the arrhythmia pathogenesis demonstrated by manifestentrainment with a long PPI. Regarding the history of cardiacsurgery in the region adjacent to the left atrium and themechanism of the arrhythmia, non-isthmus-dependent atrialflutter originating presumably in the left atrium was declared(Fig. 2).

Therefore a double transseptal puncture was performedwith continuous heparinization. Through a SL1 sheath aduodecapolar diagnostic catheter (Reflexion SpiralTM, St. JudeMedical, Inc.) was introduced and an Agilis sheath was used topass an ablation catheter (Celsius ThermoCool F Type, BiosenseWebster, Inc.); both catheters were introduced to the left atrium(Fig. 3). A 3D electroanatomic map of this chamber was thenacquired supported by 3D rotational angiography. Entrain-ment and activation mapping registered the earliest activationin the right pulmonary veins region with intermittentconcealed entrainment with a short PPI. Mapping alsodemonstrated extensive areas of fibrosis in the anterior wallwith minimal or undetectable local potentials. Because of thedifficulty of the evaluation of the activation in this region theright pulmonary veins were isolated, but no effect from thisprocedure was observed.

Due to the futility of further mapping in this region, anelectroanatomic map of the adjacent structure of the rightatrium was created. Ongoing mapping revealed a small area inthe lower posterior part of the IAS with fractionated potentials,concealed entrainment and an optimal PPI. The subsequentdelivery of RF ablation as far as the IVC caused a change in themorphology of atrial flutter and deceleration to a frequency of200/min. A typical atrial flutter was then documentedconverting to sinus rhythm after an attempt at entrainmenton the CTI. Another RF lesion completed a bidirectional blockof the CTI.

Fig. 2 – Concealed entrainment of atrial flutter with a long PPI in the septal part of cavotricuspidal isthmus.

Fig. 3 – Positioning of the catheters and the transseptalsheaths in the heart chambers.

c o r e t v a s a 5 7 ( 2 0 1 5 ) e 3 4 1 – e 3 4 6 e343

Despite sinus rhythm restoration, numerous focal atrialtachycardias were recorded with a frequency of 135/min. Theearliest activation was documented in the distal part of thecoronary sinus, resembling the original arrhythmia reported in2011. Using conventional mapping, the earliest activation wasregistered above the left atrial appendage base close to the leftsuperior pulmonary vein and this ectopy vanished after RFablation in this area (Fig. 4).

Results

Lastly, a bidirectional CTI block and the non-inducibility of anyarrhythmia were confirmed. The catheters were removed andthe transseptal sheaths were pulled down across the IVC filter.The appropriate position of the filter was evaluated with askiascopy and the procedure was terminated. No complica-tions appeared during the course of hospitalization and thepatient was discharged with a stable sinus rhythm.

Discussion

Based on published cases, there are very heterogeneouspictures of different catheter procedures in patients with an

Fig. 4 – 3D map of both the left and right atrium in LAO (a) andRAO (b) projection with ablation lesions – around the rightpulmonary veins (blue), in the right atrium terminating non-isthmus-dependent atrial flutter (red) and isthmus-dependent atrial flutter (green), on the roof of the left atriumclose to the left superior pulmonary vein (orange).

c o r e t v a s a 5 7 ( 2 0 1 5 ) e 3 4 1 – e 3 4 6e344

IVC filter. Indications for these interventions varied widely, aswell as the instrumentation used – namely central venouscatheters, EP catheters, large sheaths, cannulae of the leftventricle assist device or left atrial appendage closure. But, as faras we are concerned, not many cases of complex electrophysi-ological intervention with a double transseptal puncture andthe successful ablation of several arrhythmogenic substrates indifferent heart chambers have yet been documented.

The history of catheterization in patients with an IVC filtergoes back to the 1990s and presents about 50 cases worldwide(Table 1). In 1991, Hansen et al. performed successfuldiagnostic catheterization in seven patients with differentIVC filters, which had been placed from 1 day to 21 monthsprior to the procedure [13]. Kussmaul et al. reported a case ofright-sided heart catheterization with transfemoral access inten patients with a Greenfield filter in 2001 [14]. Noperiprocedural complications were documented and theperiod following the IVC filter implantation ranged from 5

days to 8 years. An increasing number of reported casesencouraged the performance of even more complicatedprocedures. In 2003, Rhodes et al. performed a closure of aninteratrial septum defect in four patients with IVC filtersplaced 6–24 months prior to the procedure using instrumen-tation as large as 18 Fr. [15]. In 2007, Schoeffler et al. reportedabout a similarly remarkable procedure in two patientsintroducing more massive devices – balloon mitral valvotomyand atrial septostomy [16]. There are also known cases ofelectrophysiology studies and catheter ablations in the rightheart chambers. The Czech authors Haman et al. [3] reported asuccessful RF ablation of cavotricuspid isthmus in 2006 andthe Turkish group of Erdoğan et al. did likewise in 2008 [4].Kanjwal et al. [6] documented the catheter ablation of AVNRTand atrial flutter in ten patients. In some of the cases, headvanced up to five catheters or sheaths through an IVC filter.One curiosity arising among these interventional procedureswas the placement of the left ventricle assist device throughthe filter, performed by Chiam et al. in 2008 [17], and also thesimultaneous closure of the left atrial appendage and a PFO,recently published by Martínez et al. [18].

However, catheterization in a patient with an IVC filter stillremains a rare event without an adequate single centreexperience. Despite the potential risk of serious complicationsassociated with this procedure, it is surprising that none of thestudies above reported any. In 1997, Kang et al. described twocases of Greenfield filter dislodgment caused by the insertionof central venous catheters only a few days after the filterdeployment. The other nine cases of filter dislodgment weredocumented in the literature with filters being placed for up to2 months and moving proximal or distal to the venous system,even to the right atrium [10]. Since 1993, at least 17 cases of a J-tip guide wire entrapped in the filter were reported, as statedby Vinces et al. [11]. There are also cases describing filterdamage resulting in the malfunctioning of the device [7].Presumably, not all complications in such procedures weremade known and the actual risks associated with theintervention could therefore be misrepresented.

Based on the literature review and our own experience, it isclear that certain precautions need to be taken. The correctindication for the procedure is essential. The adequacy of theperiod after the filter implantation is another importantaspect. In the presented cases the interval varied from 1 day[13] to 12 years [4]. A higher risk of complications correlates toperforming the procedures soon after the filter placement[7,10]. Thus we recommend waiting for 3–4 months to allowfilter implementation in the vessel wall and its endotheliza-tion before performing the procedure [5,13]. Appropriateperiprocedural anticoagulation therapy and ACT or aPTTmonitoring in predisposed patients is also very important. Ahigher occurrence in such patients or serious bleedingcomplications is not reported. As referred to by most authors,the patency of the filter and the absence of thrombi need to beconfirmed by primary angiography. Although IVC filters weresuccessfully crossed even with J-tip guide wires [13], themajority of authors used straight guide wires because of thelower risk of an entrapment [9,11]. All manipulations in an IVCfilter are performed under fluoroscopy guidance and safety isalso enhanced by avoiding advancing catheters directlythrough the filter without introducing sheaths [11].

Table 1 – Reported procedures across IVC filters.

Reference Procedure Pts Type of filter Implantduration

Greenfield VenaTech

Birdsnest

TrapEase

GünterTulip

OptEase

Unspecified

Hansen (1991) [13] PA 5 2 3 2 1 day to 21 monthsIVC filterplacement

2

Kussmaul (2001) [14] Right heartcatheterization

10 10 5 days to 8 years

Recto (2002) [12] TranscatheterPFO closure

1 1 Not reported

Rhodes (2003) [15] TranscatheterASD closure

4 2 2 6 days to >1 year

Henrikson (2004) [19] Extraction ofICD lead

1 1 Not reported

Awadalla (2004) [20] TranscatheterPFO closure

3 1 2 >4 weeks

Sinha (2005) [5] Pacing 1 3 months to2 yearsEPS 1

Ablation 3 5

Haman (2006) [3] AFL 1 1 9 years

Schoeffler (2007) [16] MV 1 1 9 yearsAS 1 1 1 year

Erdoğan (2008) [4] AFL 1 1 12 yearsChiam (2008) [17] LVAD 1 1 Not reported

Kanjwal (2008) [6] Palpitation 1 2x 3 monthsto >1 yearAVNRT 4 4

AVRT 1 1AFL 4 4

Martínez (2013) [18] MV 1 1 3 yearsLAA + PFOclosure

1 1 6 years

Presented report CAA 1 1 12 years

Total 48 29 4 2 1 2 2 10 1 day to 12 years

The year of publication, number of reference and name of the first author is indicated in the left column.PA, pulmonary angiography; IVC filter, inferior vena cava filter; PFO, patent foramen ovale; ASD, atrial septal defect; ICD, implantablecardioverter defibrillator; EPS, electrophysiology study; AFL, atrial flutter; MV, mitral valvuloplasty; AS, atrial septostomy; LAVD, left ventricularassist device; AVNRT, atrioventricular nodal re-entry tachycardia; AVRT, atrioventricular re-entry tachycardia; LAA, left atrial appendage; CAA,complex arrhythmia ablation.

c o r e t v a s a 5 7 ( 2 0 1 5 ) e 3 4 1 – e 3 4 6 e345

Conclusions

The presented case report accounts for the complex perfor-mance of electrophysiological intervention with a transseptalpuncture, complete electroanatomic mapping and extensiveradiofrequency ablation in several heart chambers in a patientwith an IVC filter using the transfemoral approach. Withregard to the potential high risk of complications, it isnecessary to carefully consider the risk to benefit ratio beforedeciding on such an intervention for a patient. Due to thelimited number of patients with both an IVC filter and a heartrhythm disorder suitable for catheter ablation, there is noadequate single centre experience with the methodology ofthese procedures. This is also why we cannot presume anyprospect of conducting a clinical trial focusing in detail on all ofthe risks and aspects associated with these procedures.

Conflict of interest

No conflict of interest.

Ethical statement

I declare, on behalf of all authors that the research wasconducted according to Declaration of Helsinki.

Informed consent

I declare, that informed consent requirements do not apply tothis manuscript.

c o r e t v a s a 5 7 ( 2 0 1 5 ) e 3 4 1 – e 3 4 6e346

Funding body

This work was supported by the European Regional Develop-ment Fund – Project FNUSA-ICRC (No. CZ.1.05/1.1.00/02.0123).

Acknowledgement

Mgr. Markéta Lukášová (study coordinator) provided help withregard to the language of the article.

r e f e r e n c e s

[1] H. Decousos, A. Leizorovicz, F. Parent, et al., A clinical trialof vena cava filters in the prevention of pulmonaryembolism in patients with proximal deep-vein thrombosis,New England Journal of Medicine 338 (1998) 409–415.

[2] Guidelines on the diagnosis and management of acutepulmonary embolism, The Task Force for the Diagnosis andManagement of Acute Pulmonary Embolism of theEuropean Society of Cardiology (ESC), European HeartJournal 29 (2008) 2276–2315.

[3] L. Haman, P. Parizek, R. Maly, J. Vojacek, Cavotricuspidisthmus catheter ablation across an inferior vena cava filter,Pacing and Clinical Electrophysiology 29 (2006) 331–333.

[4] A. Erdoğan, E. Şimşek, B. Akçay, Electrophysiology studiesin a patient with an inferior vena cava filter, AnadoluKardiyoloji Dergisi 8 (2008) 70–71.

[5] S.K. Sinha, D. Harnick, J.A. Gomes, D. Mehta,Electrophysiologic interventions in patients with inferiorvena cava filters: safety and efficacy in the transfemoralapproach, Heart Rhythm 2 (2005) 15–18.

[6] Y. Kanjwal, J.M. John, M.W. Burket, Passing sheaths andelectrode catheters through inferior vena cava filters: saferthan we think? Catheterization and CardiovascularInterventions 74 (2009) 966–969.

[7] E.W. Streib, J.W. Wagner, Complications of vascular accessprocedures in patients with vena cava filters, Journal ofTrauma 49 (2000) 557–558.

[8] R.D. Barraco, T.M. Scalea, Dislodgment of inferior vena cavafilters during central line placement: case report, Journal ofTrauma 48 (2000) 140–142.

[9] R.P. Liddell, D.J. Spinosa, A.H. Matsumoto, et al., Guide wireentrapment in a Greenfield IVC filter: rail and veinstechnique, Clinical Radiology 55 (2000) 878–881.

[10] S.S. Kang, M.A. Borge, M.A. Mansour, et al., Guide wiredislodgement of inferior vena cava filters during insertionof central venous catheters, Vascular and EndovascularSurgery 31 (1997) 587–593.

[11] F.Y. Vinces, T.V. Robb, K. Alapati, et al., J-tip springguide wire entrapment by an inferior vena cava filter,Journal of the American Osteopathic Association 104 (2004)87–89.

[12] M.R. Recto, W.L. Sobczyk, A novel technique to preventdisplacement of an inferior vena cava filter duringcardiac catheterization with subsequent transcatheterclosure of a patent foramen ovale in a patient withcryptogenic shock, Journal of Invasive Cardiology 14 (2002)471–473.

[13] M.E. Hansen, S.C. Geller, E.K. Yecel, et al., Transfemoralvenous catheterization through inferior vena cava filters:results in seven cases, American Journal of Roentgenology157 (1991) 967–970.

[14] W.G. Kussmaul, R. Secaira, D.J. McCormick, M. Cohen, Rightheart catheterization in the presence of an inferior venacava filter, Catheterization and CardiovascularInterventions 52 (2001) 476–478.

[15] J.F. Rhodes, S.G. Miller, G.K. Lane, L.A. Latson, Transcatheterinterventions across an inferior vena cava filter,Catheterization and Cardiovascular Interventions 59 (2003)333–337.

[16] M. Schoeffler, J. Ringewald, E. Schechter,Transfemoral venous access through inferior vena cavafilters for interventions requiring large sheaths,Catheterization and Cardiovascular Interventions 69 (2007)47–51.

[17] P.T. Chiam, C.E. Ruiz, H.A. Cohen, Placement of alarge transseptal cannula through an inferior venacava filter for tandem heart percutaneous left ventricularassist, Journal of Invasive Cardiology 20 (2008)E197–E199.

[18] G. Martínez, D. Lindefjeld, A. Martínez, Transfemoralapproach through inferior vena cava filters for complexcardiac interventions: expanding the limits, Journal ofInvasive Cardiology 25 (2013) E57–E59.

[19] C.A. Henrikson, J.A. Brinker, Extraction of a defibrillator leadthrough an inferior vena cava filter, Pacing and ClinicalElectrophysiology 27 (2004) 1568–1570.

[20] H. Awadalla, F. Boccalandro, R.A. Majano, et al.,Percutaneous closure of patent foramen ovale guided byintracardiac echocardiography and performed through thetransfemoral approach in the presence of previously placedinferior vena cava filters: A case series, Catheterization andCardiovascular Interventions 63 (2004) 242–246, http://dx.doi.org/10.1002/ccd.20174.

http://refhub.elsevier.com/S0010-8650(15)00050-8/sbref0095http://refhub.elsevier.com/S0010-8650(15)00050-8/sbref0095http://refhub.elsevier.com/S0010-8650(15)00050-8/sbref0095http://refhub.elsevier.com/S0010-8650(15)00050-8/sbref0095http://refhub.elsevier.com/S0010-8650(15)00050-8/sbref0100http://refhub.elsevier.com/S0010-8650(15)00050-8/sbref0100http://refhub.elsevier.com/S0010-8650(15)00050-8/sbref0100http://refhub.elsevier.com/S0010-8650(15)00050-8/sbref0100http://refhub.elsevier.com/S0010-8650(15)00050-8/sbref0100http://refhub.elsevier.com/S0010-8650(15)00050-8/sbref0105http://refhub.elsevier.com/S0010-8650(15)00050-8/sbref0105http://refhub.elsevier.com/S0010-8650(15)00050-8/sbref0105http://refhub.elsevier.com/S0010-8650(15)00050-8/sbref0110http://refhub.elsevier.com/S0010-8650(15)00050-8/sbref0110http://refhub.elsevier.com/S0010-8650(15)00050-8/sbref0110http://refhub.elsevier.com/S0010-8650(15)00050-8/sbref0115http://refhub.elsevier.com/S0010-8650(15)00050-8/sbref0115http://refhub.elsevier.com/S0010-8650(15)00050-8/sbref0115http://refhub.elsevier.com/S0010-8650(15)00050-8/sbref0115http://refhub.elsevier.com/S0010-8650(15)00050-8/sbref0120http://refhub.elsevier.com/S0010-8650(15)00050-8/sbref0120http://refhub.elsevier.com/S0010-8650(15)00050-8/sbref0120http://refhub.elsevier.com/S0010-8650(15)00050-8/sbref0120http://refhub.elsevier.com/S0010-8650(15)00050-8/sbref0125http://refhub.elsevier.com/S0010-8650(15)00050-8/sbref0125http://refhub.elsevier.com/S0010-8650(15)00050-8/sbref0125http://refhub.elsevier.com/S0010-8650(15)00050-8/sbref0130http://refhub.elsevier.com/S0010-8650(15)00050-8/sbref0130http://refhub.elsevier.com/S0010-8650(15)00050-8/sbref0130http://refhub.elsevier.com/S0010-8650(15)00050-8/sbref0135http://refhub.elsevier.com/S0010-8650(15)00050-8/sbref0135http://refhub.elsevier.com/S0010-8650(15)00050-8/sbref0135http://refhub.elsevier.com/S0010-8650(15)00050-8/sbref0140http://refhub.elsevier.com/S0010-8650(15)00050-8/sbref0140http://refhub.elsevier.com/S0010-8650(15)00050-8/sbref0140http://refhub.elsevier.com/S0010-8650(15)00050-8/sbref0140http://refhub.elsevier.com/S0010-8650(15)00050-8/sbref0145http://refhub.elsevier.com/S0010-8650(15)00050-8/sbref0145http://refhub.elsevier.com/S0010-8650(15)00050-8/sbref0145http://refhub.elsevier.com/S0010-8650(15)00050-8/sbref0145http://refhub.elsevier.com/S0010-8650(15)00050-8/sbref0150http://refhub.elsevier.com/S0010-8650(15)00050-8/sbref0150http://refhub.elsevier.com/S0010-8650(15)00050-8/sbref0150http://refhub.elsevier.com/S0010-8650(15)00050-8/sbref0150http://refhub.elsevier.com/S0010-8650(15)00050-8/sbref0150http://refhub.elsevier.com/S0010-8650(15)00050-8/sbref0150http://refhub.elsevier.com/S0010-8650(15)00050-8/sbref0155http://refhub.elsevier.com/S0010-8650(15)00050-8/sbref0155http://refhub.elsevier.com/S0010-8650(15)00050-8/sbref0155http://refhub.elsevier.com/S0010-8650(15)00050-8/sbref0155http://refhub.elsevier.com/S0010-8650(15)00050-8/sbref0160http://refhub.elsevier.com/S0010-8650(15)00050-8/sbref0160http://refhub.elsevier.com/S0010-8650(15)00050-8/sbref0160http://refhub.elsevier.com/S0010-8650(15)00050-8/sbref0160http://refhub.elsevier.com/S0010-8650(15)00050-8/sbref0165http://refhub.elsevier.com/S0010-8650(15)00050-8/sbref0165http://refhub.elsevier.com/S0010-8650(15)00050-8/sbref0165http://refhub.elsevier.com/S0010-8650(15)00050-8/sbref0165http://refhub.elsevier.com/S0010-8650(15)00050-8/sbref0170http://refhub.elsevier.com/S0010-8650(15)00050-8/sbref0170http://refhub.elsevier.com/S0010-8650(15)00050-8/sbref0170http://refhub.elsevier.com/S0010-8650(15)00050-8/sbref0170http://refhub.elsevier.com/S0010-8650(15)00050-8/sbref0170http://refhub.elsevier.com/S0010-8650(15)00050-8/sbref0175http://refhub.elsevier.com/S0010-8650(15)00050-8/sbref0175http://refhub.elsevier.com/S0010-8650(15)00050-8/sbref0175http://refhub.elsevier.com/S0010-8650(15)00050-8/sbref0175http://refhub.elsevier.com/S0010-8650(15)00050-8/sbref0175http://refhub.elsevier.com/S0010-8650(15)00050-8/sbref0180http://refhub.elsevier.com/S0010-8650(15)00050-8/sbref0180http://refhub.elsevier.com/S0010-8650(15)00050-8/sbref0180http://refhub.elsevier.com/S0010-8650(15)00050-8/sbref0180http://refhub.elsevier.com/S0010-8650(15)00050-8/sbref0185http://refhub.elsevier.com/S0010-8650(15)00050-8/sbref0185http://refhub.elsevier.com/S0010-8650(15)00050-8/sbref0185http://dx.doi.org/10.1002/ccd.20174http://dx.doi.org/10.1002/ccd.20174

Complex electrophysiology intervention in a patient with an inferior vena cava filterIntroductionCase reportMethodsResultsDiscussionConclusionsConflict of interestEthical statementInformed consentFunding bodyAcknowledgementReferences