Europace Advance Access originally published online on January 31, 2007
Europace 2007 9(3):200-201; doi:10.1093/europace/eul183
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CARDIAC PACING
A novel technique for right ventricular lead placement in a patient with a persistent left superior vena cava
Division of Cardiac Electrophysiology, University of Utah Health Science Center/Salt Lake City VA Administration Hospital, 30 North 1900 East, 4A100, Salt Lake City, UT 84132, USA
Manuscript submitted 21 August 2006. Accepted after revision 19 November 2006.
* Corresponding author. Tel: +801 581 7715; fax: +801 581 7735. E-mail address: mohamed.hamdan{at}hsc.utah.edu
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Abstract |
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Persistent left superior vena cava is the most common venous anomaly of the thorax. If unrecognized, it could lead to catheter malplacement and even vascular injuries. We describe a novel use of a Worley sheath for the delivery of a right ventricular (RV) endocardial pacing lead in a 65-year-old male with a persistent left superior vena cava. After failed attempts with the standard stylets, use of the Worley sheath aided successful lead deployment. We conclude that when used appropriately, the Worley sheath is a tool that could be helpful in pacing lead placement in patients with persistent left superior vena cava.
Key Words: Persistent left superior vena cava, Right ventricle pacing lead deployment, Worley sheath
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Introduction |
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Unusual venous anatomy can be encountered when implanting pacemakers or defibrillators. Persistent left superior vena cava (SVC) is the most common venous anomaly of the thorax with a prevalence as high as 11% in patients with congenital heart disease.1
Various techniques consisting mainly of custom formed stylets allowing navigation through the complex venous anatomy have been described in the literature.2 We report a new approach for lead delivery that could significantly decrease radiation exposure and improve patient safety. |
Case report |
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A 65-year-old male with a past history of coronary artery bypass graft surgery in 1997 and symptomatic sinus node dysfunction was referred to the electrophysiology laboratory for dual chamber pacemaker implantation. Echocardiography performed at an outside hospital revealed a mildly depressed left ventricular ejection fraction with no significant valvular heart disease. During the initial left subclavian venous puncture, findings compatible with persistent left SVC were observed and the anomaly was ultimately confirmed by contrast venography showing drainage into the right atrium via the coronary sinus. Limited attempts were made at placing the right ventricular (RV) lead using standard stylets without any success. Next, a 40 cm 9 F CSG Worley® sheath (Pressure Products Inc, San Pedro, CA, USA) was introduced over a 0.375 mm guide wire to navigate into the right ventricle through the coronary sinus using the previously obtained left subclavian venous access. Within 2 min after Worley sheath deployment, an active fixation lead was advanced across the tricuspid valve and positioned in the right ventricle apex without any complications (Figure 1). Subsequently, an active fixation lead was placed over the right atrial lateral wall using a standard curved stylet. A limited 2D echocardiogram demonstrated appropriate RV lead placement.
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This new tool allowed the rapid delivery of the pacing lead into the RV apex without any complications, reducing the procedure and fluoroscopy times compared with further attempts with stylet-driven leads.
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Discussion |
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Persistent left SVC is an anatomical variant with an incidence of 0.3–11% in the general population. In 90% of cases, both right and left SVCs are present with the left SVC draining into the right atrium via the coronary sinus. In rare cases, the right SVC is absent, and in 70% of cases the innominate vein may not be present.3
When isolated, this anomaly is usually not recognized until a transvenous approach is used for diagnostic or therapeutic purposes. Its presence is suggested when the guide wire begins an early inferior approach at the junction of left subclavian and left internal jugular vein. Venography is required to confirm the diagnosis and when present, access to the right subclavian vein is recommended to facilitate lead placement.
In patients with persistent left SVC, the transvenous introduction of a lead into the right ventricle could be challenging, particularly when the right SVC or innominate vein are absent. Various techniques including new coronary sinus cannulation systems and steerable stylets have been described in the literature.2 Although effective, they can often be time consuming and may increase radiation exposure to both the operator and the patient.4 We report an alternative use of a Worley sheath for the placement of a RV lead in the presence of this anomaly. The CSG Worley® sheath allowed the rapid placement of a RV lead into the apex, minimizing implantation time and radiation exposure. The sheath was easily removed using a peel-away technique. We conclude that when used appropriately to minimize venous dissection and perforation, the CSG Worley® sheath is a tool that could be helpful in patients with persistent left SVC.
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References |
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[1] Ratliff HL, Yousufuddin M, Lieving WR, Watson BE, Malas A, Rosencrance G, et al. Persistent left superior vena cava: case reports and clinical implications. Int J Cardiol 2006; 113: 242–6.
[2] Markewitz A and Mattke S. Right ventricular implantable cardioverter defibrillator lead implantation through a persistent left superior vena cava. Pacing Clin Electrophysiol 1996; 19: 1395–7.[CrossRef][Medline]
[3] Pai RK and Cadman CS. Persistence with a persistent left and absent right superior vena cava. Cardiol Rev 2005; 13: 163–4.[CrossRef][Medline]
[4] Kapetanopoulos A, Peckham G, Kiernan F, Clyne C, Kluger J, Migeed MA. Implantation of a biventricular pacing and defibrillator device via a persistent left superior vena cava. J Cardiovasc Med (Hagerstown) 2006; 7: 430–3.
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