Biventricular Intracardiac Device Implanted in a Patient with Persistent Left Superior Vena Cava

A 66-year-old man with acute-on-chronic systolic dysfunction was referred for cardiac resynchronization therapy with a biventricular implantable cardiac defibrillator (CRT-D) after he was found to have a left ventricular ejection fraction of 0.15, left bundle branch block, and a QRS interval of 190 ms. The patient had a history of New York Heart Association functional class III congestive heart failure and ischemic cardiomyopathy. After a left axillary venogram showed no occlusions, access to the left axillary vein was attained. The right ventricular and right atrial leads of the CRT-D device (Medtronic, Inc.; Minneapolis, Minn) were placed in the right ventricular apex and right atrial appendage, respectively. After gaining access to the coronary sinus (CS) with difficulty, we performed contrast venography, which revealed a persistent left superior vena cava (SVC) (Fig. 1). The left ventricular (LV) lead of the CRT-D device was positioned in the posterolateral branch of the CS via the CS ostium. All lead thresholds and positions were optimal.

Fig. 1 Venogram shows a persistent left superior vena cava (arrows) draining into the coronary sinus. Contrast medium was injected from the coronary sinus ostium.

One day after the procedure, device interrogation showed loss of capture of the LV lead. The patient was returned to the cardiac catheterization laboratory, and the LV lead was retracted. After several unsuccessful attempts to regain access via the CS ostium, we entered the CS via the persistent left SVC with use of a 5F, 90°-angled glide catheter and a 0.035-in glide wire. The glide wire was then exchanged for a 0.035-in super-stiff Amplatz® guidewire (Boston Scientific Corporation; Natick, Mass) to provide further support. Subsequently, the glide catheter was exchanged for an Attain Select® II sub-selective catheter (Medtronic) over the Amplatz guidewire. The LV lead was advanced through the catheter and was placed in the high posterolateral branch of the CS. The lead capture thresholds were not stable in this position because of the extreme proximal tortuosity of the branch. By means of the same technique, the lead was placed in a lower posterior branch of the CS (Fig. 2) and advanced over a 0.014-in HI-TORQUE WHISPER guidewire (Abbott Vascular, part of Abbott Laboratories; Santa Clara, Calif) (Fig. 3). Intraoperative and 24-hour postoperative device interrogation showed normal thresholds. The patient was discharged from the hospital without complications. One month later, the lead position and capture threshold were stable.

Fig. 2 Venogram shows the posterolateral branch of the coronary sinus (arrow). With use of the Attain Select II catheter, a superior approach was taken from the persistent left superior vena cava.

Fig. 3 Venogram (left anterior oblique view) shows the left ventricular lead after its delivery to the posterolateral branch of the coronary sinus. A superior approach was taken from the left axillary vein (asterisk) to the persistent left superior vena cava (arrow) and posterolateral branch of the coronary sinus (double arrow).

Comment

Persistent left SVC, the most common venous anomaly of the thorax, occurs in 0.3% of the population.^1,2 This condition is usually asymptomatic, and it can be detected incidentally by venography during device implantation. In our patient, we showed the feasibility of LV lead placement via a persistent left SVC during CRT-D device implantation.