Cardiac Defibrillator Implantation via Persistent Left Superior Vena Cava

Abstract

A 62-year-old gentleman with ischemic cardiomyopathy and an ejection fraction estimated at 30% got admitted to the hospital for recurrent syncope, and was found to have non sustained ventricular tachycardia on ECG monitoring. He was referred to the electrophysiology (EP) laboratory for implantation of an implantable cardioverter defibrillator (ICD).In the EP lab, under sterile fashion, a left infraclavicular incision was made for creation of the pocket then the left subclavian vein was accessed utilizing the first rib approach. A guide wire was advanced into the vein but it took a vertical course. We confirmed that the venous system was accessed, not the subclavian artery, by examining the color and the flow of the blood. Advancing the wire further down resulted in a horizontal shape of the wire at the diaphragmatic side of the heart followed by a loop in the right lateral edge of the cardiac silhouette. The dilator was first advanced without the sheath and a venography was performed confirming the presence of a persistent left superior vena cava (PLSVC).At this point a 9 French sheath was advanced then an active fixation dual coil lead (Reliance, 0184, 59 cm, Boston Scientific, MN, USA) was inserted down the PLSVC through the coronary sinus and first parked in the right atrium.A soft stylet was shaped manually creating a large J curve. This was advanced into the lead and an extreme counterclock steering of the stylet prolapsed the lead in the right ventricle outflow tract. The stylet was then withdrawn about 1 cm and gently the whole system was pulled back. This allowed the tip of the lead to fall to a mid-septal position. Measurement of the R waves there showed amplitude of more than 12 mV so we decided to fix the lead in that position (Figure 1).The lead was secured to the muscle then connected to the generator. Defibrillation was performed at 15 joules delivered energy after induction of ventricular fibrillation 94 Nakad GF, Bayeh H, Abi Saleh B. Cardiac defibrillator implantation via persistent left superior vena cava. J Med Liban 2015 ; 63 (2) : 94-96. Nakad GF, Bayeh H, Abi Saleh B. Implantation d'un défibrillateur cardiaque interne à travers une veine cave supérieure gauche. J Med Liban 2015 ; 63 (2) : 94-96. RÉSUMÉ • La persistante de la veine cave supérieure gauche est une variante anatomique peu fréquente.Nous rapportons un cas d'implantation d'un défibrillateur cardiaque interne à travers une veine cave supérieure gauche, en prenant compte de l'aspect technique et en décrivant les implications cliniques associées à une telle procédure. ABSTRACT • Persistent left superior vena cava (PLSVC) isan uncommon anomaly. We describe a case of a left-sided implantation of an implantable cardioverter defibrillator (ICD) through a PLSVC, assessing the technical approach to such a procedure, along with a review of the clinical implications that might ensue.Learning objectives : LSVC is a rare anatomical venous variation. Knowledge of its presence and clinical implications will render a lead implantation safer and w...