LEFT SIDED APPROACH FOR IMPLANTATION OF DUAL CHAMBER PACEMAKER IN PATIENT WITH PERSISTENT LEFT SUPERIOR VENA CAVA AND COMPLETE AV BLOCK
Authors: Vesna Bisenic, Branislav Milovanovic, Predrag Djuran, Sanja Djordjevic, Aleksandra Djokovic, Nebojsa Ninkovic, Jasmina Korica Tresnjak, Dejan Jovic, Tatjana Loncar-Turukalo, Vera Radivojevic, Sasa Hinic
Background: Persistent left superior vena cava(PLSVC) represents a congenital vascular defect of venous system, which makes standard endocardial lead placement difficult. Regarding the way of joining PLSVC to the heart, two anatomic varieties are described: PLSVC joins the rigth atrium over the dilated coronary sinus(CS); variations joining PLSVC to the left atrium. Incidence of PLSVC is 0,30 to 0,50% in general population, and 4% of those having congenital defects.
Case outline: A 50-year-old male was addmited to the Coronary Care Unite due to complete AV block and repeated syncopal episodes. Holter monitoring showed intermitent AV block of II and III degree with minimal heart rate of 33/min, and the longest pause of 4,88sec. Echocardiographic finding was normal except moderate aortic regurgitation. The patient underwent DDDR pacemaker implantation. Right chamber approach by right cephalic and subclavian vein was impossible, the electrode lead passed to the left side. By cubital vein contrast injection diagnose of PLSVC was made. Approach by the left side and alternative method of pacing through the CS was considered. Venography was peformed, but unipolar lead for CS (SJM, QUICKFLEX,1156T/86cm) could not be placed due to anatomic difficulties. The activ electrode leads (SJM, TENDRIL 1888TC/58cm) were placed in RVOT and right atrium (lateral wall). The values that were achived were normal at the implantation and one year after (treshold, maximum R and resistance).
Conclusion: Persistant left superior vena cava makes standard right chamber approach by the right cephalic and subclavian vein impossible. Approach by the left side in some cases is difficult due to joining of PLSVC to the right atrium over the dilated coronary sinus. The standart endocardial 58cm lead could be too short for these patients. Coronary sinus lead placement and placement in RVOT(right ventricular outflow tract) represent an alternative approach for pacemaker lead placement in these patients.