Persistent left superior vena cava and pacemaker implantation

Abstract

Our study group read with interest the paper from Vijayvergiya et al describing the implantation of an implantable cardioverter-defibrillator lead in the presence of the persistence of the left superior vena cava. The issue of the identification a persistent left superior vena cava is of paramount importance in interventional cardiology, being the most common venous anomaly of the thoracic distribution, and because it may create some problem to any physician while performing a pacemaker lead implantation. In our letter we underscore the specific issues related to pacemaker implantation while encountering a persistent left superior vena cava (and maybe the absence of the right vena cava) and the workup that should be performed to obtain the preoperative diagnosis of the venous anomaly. More specifically, we consider avoiding any kind of defibrillator lead implantation through the coronary sinus for safety issues, and underscore the straightforward transthoracic ultrasound approach to identify the left superior vena cava. LETTERS TO THE EDITOR TO THE EDITORWe have read with interest the contribution from Vijayvergiya et al [1] , who describe a tricky case of implantable cardioverter-defibrillator (ICD) implantation facing the persistence of the left superior vena cava (PLSVC).A few years ago we experienced a similar situation with a VVI pacemaker implantation [2] : nonetheless, we would like to underscore some peculiar and personal features we think should always be born in mind before a pacemaker is implanted. Firstly, a complete ultrasound examination should be obtained before implantation in order to rule out anatomical difficulties, e.g., PLSVC. In our case we did not perform an echocardiogram because of the precipitating clinical situation, but in routine settings the EP physician should always be aware of detailed cardiac anatomy. Secondly, we discourage lead implantation-especially of an ICD lead, when the existence of a right vena cava has been proven even though the procedure has started with a left-side approach. Caution is needed when trying to place any kind of lead through the coronary sinus in order to avoid ominous tears or dissections [3] .

Permanent pacemaker implantation in a challenging anatomy: Persistent left superior vena cava

“…The literature is quite poor in cases of implantation of the transvenous pacing electrodes through a persistent left superior vena cava. What is really difficult is the positioning of the right ventricular electrode because of the sharp angles which the lead has to travel to the final position, either at the apical level or at the level of the interventricular septum [7][8][9][10][11][12][13]. Theoretically, those sharp angles of the ventricular lead seem to have an increased risk of lead fracture but we did not find any reported case of right ventricular lead fracture placed through a PLSVC.…”

Imaging topography and morphometry of persistent left superior caval vein and its variations, detected on cardiac implantable electronic device implantation

“…Literature reports typically present isolated cases of a specific PLSCV variation [4,11,16,19,25]. This article presents PLSCV topography and morphometry in 10 cases of this venous malformation diagnosed during CIED implantation procedures, based on various techniques used to visualize each of the three representative variations.…”