|Year : 2016 | Volume
| Issue : 1 | Page : 71-73
Persistent left superior vena cava: A challenge for permanent pacemaker implantation
Abraham Speedie, Cinosh Mathew, Rajneesh Calton
Department of Cardiology, Christian Medical College and Hospital, Ludhiana, India
|Date of Web Publication||22-Dec-2015|
Department of Cardiology, Christian Medical College and Hospital, Ludhiana
Source of Support: None, Conflict of Interest: None
Persistent left superior vena cava is the most common variation in the anomalous venous return to the heart. It is usually asymptomatic and discovered incidentally during imaging and the aberrant position of a pacemaker lead, central venous catheters, or retrograde cardioplegia for cardiac surgery. We present two different approaches of pacemaker implantation in this congenital anomaly.
Keywords: Anomalous venous return, Pacemaker, Persistent left superior vena cava
|How to cite this article:|
Speedie A, Mathew C, Calton R. Persistent left superior vena cava: A challenge for permanent pacemaker implantation. CHRISMED J Health Res 2016;3:71-3
|How to cite this URL:|
Speedie A, Mathew C, Calton R. Persistent left superior vena cava: A challenge for permanent pacemaker implantation. CHRISMED J Health Res [serial online] 2016 [cited 2019 Oct 14];3:71-3. Available from: http://www.cjhr.org/text.asp?2016/3/1/71/172388
| Introduction|| |
Persistent left superior vena cava (PLSVC) is the most common variation in the anomalous venous return to the heart and accounts for 0.2–4.3% of all congenital cardiac anomalies. Associated absent right superior vena cava (RSVC) in an otherwise normal heart is an exceedingly rare anomaly. These venous anomalies are usually asymptomatic and discovered incidentally during imaging and the aberrant position of a pacemaker lead, central venous catheters, or retrograde cardioplegia for cardiac surgery. A left superior vena cava (LSVC) is not very uncommon, yet it poses challenges when permanent pacemaker implantation is contemplated.
| Case Reports|| |
A 43-year-old male was admitted with a history of recurrent episodes of dizziness and uneasiness for 4 years. His electrocardiogram (ECG) showed atrial fibrillation with long sinus pauses. His echocardiography (ECHO) revealed normal sized cardiac chambers, normal color flow mapping, and left ventricular ejection fraction (LVEF) of 60%. During the attempt to perform temporary pacemaker insertion via femoral vein, it was detected that inferior vena cava was draining via an azygous vein. As temporary pacemaker insertion via femoral route was unsuccessful, an upper limb approach using right brachial cutdown was attempted. However, the temporary pacemaker lead could not be negotiated to the right ventricle (RV). Therefore, transvenous permanent pacemaker implantation was considered technically not possible. In view of delineating the anatomy of the upper limb a venogram was done, and he was detected to have a persistent LSVC draining into the right atrium (RA) via the coronary sinus (CS). He was then taken up for an epicardial pacemaker implantation [Figure 1]. Anterior thoracotomy was done from 6th intercostal space, and the 6th rib was cut anteriorly. After opening pleura and pericardium, the epicardial pacing leads (Medtronic 5071-53 cm sutureless, unipolar myocardial screw-in pacing lead, USA) were positioned over the myocardium. A subcutaneous pocket was created below the xiphisternum, and single chamber pacemaker (Sigma SS103 Medtronic, USA) was placed in the pacemaker pocket and connected to the lead. The patient, since then has been on follow-up and has not had any problems with parameters remaining stable.
|Figure 1: Chest and abdominal X-ray of Case 1 showing the epicardial pacemaker and leads in situ|
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A 74-year-old smoker was admitted with episodes of presyncope for 1.5 years which had increased for 10 days prior to admission. He had dyspnea of NYHA Grade II–III for 4–8 months. His ECG showed sinus bradycardia with right bundle branch block. An ECHO showed normal sized cardiac chambers with normal contractility and LVEF of 60%. He had temporary pacemaker implantation done. He underwent coronary angiography which revealed normal coronaries. He was then planned for permanent pacemaker implantation. The approach during pacemaker implantation was to do a cutdown of the right cephalic vein and advance the lead into RV apex. However, as the lead was advanced, it went to the left side of the thorax. Venogram performed to confirm the lead path showed an anomalous route where the right subclavian vein drained into the LSVC and then into RA via the CS. This route was followed for the ventricular lead (Biotronik Selox ST 60) placement. A loop was made in RA, and the lead was then positioned at the RV apex [Figure 2]. After securing a position with stable pacing threshold and sensing, it was anchored to the subcutaneous tissue in the right infraclavicular region. A subcutaneous pocket was created in the right infraclavicular region for pacemaker implantation.
|Figure 2: Posterioranterior view of the chest showing the pathway of the permanent pacing lead from left superior vena cava to coronary sinus to right atrium with a loop in RA to right ventricular apex|
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| Discussion|| |
A PLSVC results from the persistence of the embryonic left anterior cardinal vein. In the most common form of PLSVC, both left and right SVCs are present. Chest X-ray is routinely performed after a central venous access has been established, and a dilated CS (>1 cm) on ECHO and raise the suspicion of the anomaly.
The infusion of agitated saline injection from the left or right antecubital vein results in opacification of the RA on Echocardiogram. In the cases where the right SVC accompanies the PLSVC, contrast given from the left arm first appears in the CS, whereas contrast given from the right arm first appears in the RA. In 10% of patients, a PLSVC may drain into the left atrium either directly or via an unroofed CS; in such a situation, contrast first appears in the left atrium. Other imaging modalities such as venous computed tomography or magnetic resonance imaging, directly visualize the venous anatomy, and confirm the diagnosis.
Implantation of pacemaker leads through a PLSVC constitutes a challenging procedure since the lead enters the RV through the CS, making the maneuvering of pacing lead into the RV technically difficult. The existence of an acute angle between the CS ostium and the tricuspid valve makes it necessary that the lead should be looped in the RA in order to enter the RV. Successful pacemaker implantation in cases of isolated PLSVC have been reported in the literature, whereby a long (85 cm) active fixation lead could be manipulated to enter the RV by the use of the wide loop technique. As our patient (Case 2) was small built, we used a standard 60 cm lead. In case of dual chamber pacemaker implantation, a second lead is screwed into the right atrial wall.
Pacing through the tributaries of the CS or a middle cardiac vein in patients with PLSVC have also been reported. A dilated CS on ECHO should raise the suspicion of PLSVC. The diagnosis should be confirmed by the saline contrast ECHO. Physicians should consider the presence of PLSVC whenever, a catheter or a guide wire inserted via the left subclavian vein takes an unusual left-sided downward course. A PLSVC, especially in the absence of a right SVC, presents technical difficulties, and risks during the insertion of leads into the right heart chambers for implantation of pacemakers or implantable cardioverter defibrillators. Various approaches have been advocated by some authors including epicardial pacing.
| Conclusion|| |
PLSVC can cause challenges in implantation of permanent pacemaker leads. We have here described two patients in which different approaches have been used to implant the permanent pacemaker leads.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]